Controversial Ideas in Medicine

Overview

Generally speaking, we can split psychiatric diagnoses in the following way:

1. Axis I: major psychiatric disorders such as schizophrenia, depression, anxiety, autism, substance abuse disorders, attention deficit disorder, delirium
2. Axis II: disorders of personality
3. Axis III: medical (read: biological) diagnoses which contribute psychologically, such as thyroid disorders, cancers, etc
4. Axis IV: psychosocial support network
5. Axis V: global assessment of function score (0-100, 0 = death, 100 = fully functional)

What is a disorder of personality? How can you have a disordered personality as such? Simply put, a personality disorder occurs when someone has:

• A stable, ongoing pattern of behaviour, thoughts, emotions and social function (since adolescence or early adulthood)
• That differs markedly from the cultural norm
• Causes significant social/occupational/functional impairment or distress
• And is not better accounted for by another mental, medical disorder or substance use

So, that asshole who antagonises every client without fail and gets constant complaints about him? The 30 year old drama queen (male or female) who is always full of gossip and never seems particularly sincere? The suspicious weird old lady down the street who everyone is convinced is a witch? That guy at work who always lets everyone walk all over him? That needy, intense woman who stalks her exes? These are examples of potential personality problems. It is their personality, the exaggerated nature of their behaviour, emotions, thoughts, interactions that is at fault. This is not to say that personality is not something which has a great deal of normal individual variation. All the above four features need to be fulfilled for this to be a personality disorder. Simple eccentricity, oddness, quirkiness or other differences are not a disorder- for something to be a personality disorder it needs to cause some sort of ongoing functional impairment or distress. Nor does it mean that someone with a personality disorder is incapable of future functionality because it is their intrinsic personality which is problematic- it is certainly quite possible for someone to moderate their behaviour, thoughts, emotions.

"Everyone has a personality with character traits such as stinginess, generosity, arrogance and independence. But when these traits are rigid and self-defeating, they may interfere with functioning and even lead to psychiatric symptoms. Personality traits are formed by early adulthood, persist throughout life and affect every aspect of day to day behavior. Individuals with personality disorders often blame others for their problems."

-BehaveNet.com In addition, they may find some difficulties with their attachment styles.

The Clusters

Cluster A

Cluster A can be considered the "aloof, suspicious" group. They have in common propensities to some of the "negative" symptoms of schizophrenia - ie social withdrawal, suspiciousness, flattened emotions etc.

Paranoid Personality Disorder

This personality disorder is exactly what it says on the packet; it is characterised by an excessively suspicious, paranoid nature. People who suffer from this tend to be constantly questioning others' motives and see others as a threat. They are preoccupied with ideas of lack of loyalty and others' trustworthiness. They also bear grudges strongly and tend to take offence easily as they believe others to be attacking them.

Schizotypal Personality Disorder

Schizotypal personality disorder is what can almost be considered to be part way on the spectrum of schizophrenia itself (though much milder). In fact, family members of people with schizophrenia and related disorders are much more likely to have this personality disorder. It is a disorder which is in fact characterised by the less paranoid and more, well, odd features of schizophrenia - albeit without being floridly psychotic. This includes- eccentric behaviour, speech and ideas, belief in magical and superstitious things, paranoia, social anxiety and a withdrawn nature, flattened emotions.

Schizoid Personality Disorder

These people tend to be socially uninterested and somewhat indifferent. They do not really miss the lack of social closeness with others, nor the variety of experiences. Praise and criticism does not really affect them. They seem somewhat aloof, but not because of nervousness, just because of a very solitary nature.

Cluster B

Cluster B personality traits are characterised by extroverted, emotionally unstable and often anxious and/or aggressive behaviour. In addition, there are often distortions of self-esteem, self-identity and impaired empathy.

Psychopathy

Psychopathy is a disorder which was previously included in the DSM in place of the rather contentious and amorphous Antisocial Personality Disorder. There are said to be two major trait factors involved in psychopathy. Factor 1, "Aggressive Narcissism", connotes the selfish, remorseless, callous, charming, grandiose, shallow, flirtatious traits. Factor 2, "Socially Deviant Lifestyle" connotes the emotionally unstable, antisocial, violent, deviant, impulsive, parasitic, delinquent, stimulation-seeking traits. Thus, psychopaths lack empathy, are emotionally labile and generally superficially charming, very manipulative and guilt-free; they are impulsive, irresponsible, uncontrolled, hedonists. This category overlaps with both Narcissistic, histrionic personality disorders and Antisocial personality disorder.

Narcissistic Personality Disorder

Once again, the narcissist is what the label says. They are egocentric and believe they are self-important, unique, special and worthy of special treatment and rewards. They are obsessed with fantasies of power, success, beauty; they are manipulative, lack empathy, are arrogant and fluctuate between envy and the belief that everyone wants to be just like them.

Histrionic Personality Disorder

Histrionic means what most people think of as "hysterical"- these are what most would term the "drama queen". Attention-seeking, flirtatious, shallow, dramatic, with swinging moods and a bit, well, intense. Larger than life, and quite full-on.

Antisocial Personality Disorder, Conduct Disorder

Antisocial Personality disorder encompasses 2 main types of traits- the psychopathic traits as defined above as well as criminality. Needful to this diagnosis is also the diagnosis of Conduct Disorder, the juvenile equivalent of this disorder. Conduct Disorder has several categories of behaviour: aggression to people and animals; destruction of property; lying/theft; serious violations of parental rules.

Borderline Personality Disorder

Borderline personality disorder is a very overrepresented category of person who presents to hospitals, in particular to emergency departments. These people are strange cookies, and it is very likely you have met at least one- it is a fairly common disorder with an incidence of roughly 2%. BPD involves very unstable relationships, self-image, emotions and very impulsive behaviour. They are clingy and needy as they are constantly in fear of being abandoned. They alternately idolise and demonise people, often rapidly. They have little sense of who they are and think of themselves often as an empty void. They very often self-harm, threaten and attempt suicide - often as a response to their extreme anxiety. Their moods swing violently; they are often uncontrollably angry and sad. They do impulsive things, including self-destructive sexual relationships, gambling, spending. Under extreme circumstances they can become paranoid or even have anxiety related dissociation.

Cluster C

These are the anxious personality disorders. People who have always been a bit nervous. One can think of these disorders almost as the over-controlled, introverted counterparts to the Cluster B disorders.

Avoidant Personality Disorder

These people are inhibited, inadequate and over-sensitive to criticism and have poor self-esteem. In an attempt to avoid censure, rejection, embarrassment, they avoid social contact, relationships, any sort of risk. They believe themselves to be inferior, unappealling, inept, unloveable. They are shy.

Dependent Personality Disorder

Dependency in this case comes from a need to be taken care of, inability to make one's own decisions and fear of being left alone. There is difficulty making decisions without reassurance, advice; a need for others to take responsibility; inability to start things without others' support; neediness, passivity and submissive behaviour due to fear of rejection if they are assertive; fear of being alone and need for a constant relationship.

Obsessive-Compulsive Personality Disorder

OCPD is what the lay person may think of as an obsessive-compulsive person. Someone who is anally retentive, obsessed with organisation, perfection, lists, rules, work, productivity, morality. They are rigid, perfectionistic, can be miserly and sometimes even hoard things.

Passive-Aggressive Personality

This is sometimes included as part of Cluster C. Passive-aggressive people are unassertive and have difficulty expressing anger. As a result, they are resentful, sullen and express their anger through passive forms such as inviting criticism, performing poorly, being obstructive.

Not Otherwise Specified

Yes, they meet the criteria for a personality disorder but it does not fall neatly into a category, or is undefined by the above clusters. While people may fit easily into a personality disorder category, it is sometimes more useful to conceive of personalities as containing personality traits, cluster traits or similar.

What is Rape

Sexual assault (including rape as sub-category) is a common crime in Australia affecting 0.3-0.7% of the total population per year and affecting close to 20% of 18-24 year old women in the past 12 months(!) Only 15% of sexual assaults are reported to the police. Let us define rape. This is difficult as can be evidenced by a quick google search for definitions of rape. Let us go with the following for now:

"Rape is defined as forced, manipulated or coerced sexual intercourse (or other sexual act) against the will of the victim. If the act occurs while the victim is unconscious, asleep or otherwise unable to communicate unwillingness, it is still considered rape."

(As per Massacheusetts law)

What is Stalking

Stalking too is a common phenomenon, affecting some 23% of people throughout their lifetime, and with rates of 32% amongst people aged 18-35. There are various definitions of stalking in legal and academic literature. The nature of the behaviours and the intent are controversial areas- if the intent is romantic in nature, is it stalking? Similarly, if it is a seemingly innocent gesture but is repeated and done in such a way to cause (reasonable) fear, is it stalking? Consensus however is reached when it comes to the effect on the victim: it is necessary that the conduct causes the victim to fear for his/her safety. Thus I use the following definition:

"Stalking refers to a course of conduct by which one person repeatedly inflicts on another unwanted intrusions to such an extent that the recipient fears for his or her safety."

(Purcell, Pathé, Mullen 2004)

Who Rapes, Stalks- and Why?

Many models have been proposed for rape, stalking, sexual murder and sexual assault, striving to represent the diversity of motive and execution evident in the crime.

Summary of Convicted Rapists

Not all rapists (I must point out once again) are psychopathic- fully half are non-psychopathic. >95% of reported rapes have a male perpetrator. However female rapists are likely very underrepresented due to sociocultural factors and attitudes. It is also to be noted that rapists carry a recidivism rate (for all crimes) of roughly 50%- the highest rate for violent offenders; convicted paedophiles carry a rate of between 10-50% depending on study and subcategorisation, which includes both child rapists as well as those attracted to children.

Summary of Convicted Stalkers

Stalking has only recently entered the popular lexicon despite reports of stalking behaviours since at least the 1800s; it became a common term only some time in the 1980's, as a response to celebrity stalkers. This became more generalised to harrassment and predatory behaviour towards non-famous victims. In contrast with rape, the gender split with perpetrators is roughly 50/50. Once again, this difference may represent greater social acceptability for people to report female stalkers than female rapists. Various studies of stalkers have also shown that concurrent psychiatric problems (whether psychosis, mood disorder or personality related) were almost universal in this group.

The FBI Model of Violent Crime

The FBI have a model which divides rapists (and other violent criminals) into "organised" and "disorganised" subtypes. Organised being those who plan carefully, leave few traces of their crime, do not do random acts of "ultra-violence". Disorganised being those who display "chaotic" features (such as ultra-violence, lack of planning, messiness, etc.) The FBI model has very little evidence to back it and unsurprisingly is widely derided as simplistic, artificial, unreaistic and, well, incorrect.

More Modern Typologies of Rape, Stalking and Sexual Murder

The only reason for the multiplicity of categories in the diagram below is because of the overlap present in the typologies of rapists, sexual murderers and stalkers in the studies below. These studies took data from crime scenes, criminals and victims and came up with distinct behavioural and motivational clusters. (Click for larger version) However, when you compare the studies it would be more accurate to speak of roughly 6 subtypes as follows:

• 1a: Violent, aggressive types who are motivated by pure revenge against the victim. Thus, entirely violent, paranoid motivations, associated with paranoia as well as Cluster B* (antisocial, narcissistic, borderline, histrionic) personality traits.
• 1b: Violent, angry and power-obsessed types who are motivated because of (perceived) rejection by the victim. Thus, sex/intercourse is also a factor. Associated with Cluster B traits.
• 2a: Socially inept, intimacy seeking, incompetent types who do not know any other sure-fire method of procuring intimacy/intercourse and/or who rape because they feel socially inadequate and insecure. They are purely motivated by the desire for sex/intimacy and only use as much force is necessary to get what they want. Murder is an accidental sequel to this. Usually socially inept/of low IQ.
• 2b: Delusional, intimacy seeking types who believe that their victim is in love with them back. Associated with psychosis and schizophrenia.
• 3: Sadistic, fetishistic, predatory types who plan meticulously and whose motivation is complex violent sexual fetish- an extreme form of the combination of sex and violence. Very dangerous, unrepentant, skilled. Associated with psychopathy and extreme paraphilias.
• 4: "Other". This more nebulous group includes oppportunistic, inept, short term, unplanned acts of random violence, often associated with the commission of other crimes including robbery.

*Cluster B personality disorders include: antisocial (violence, disregard for others' rights, egocentrism, low empathy, includes the subgroup of psychopaths), narcissistic (egocentricity, inflated self-esteem, callous disregard for others), histrionic (attention-seeking, shallow but dramatic moods, egocentrism, overdramatic), borderline (unpredictable behaviour, low self-esteem, inner emptiness, clingy behaviour, mood swings, rapid change from idolisation to demonisation). This group of disorders has high overlap and there is a (possibly cultural) propensity for men to be diagnosed (or misdiagnosed) with APD or narcissism vs women and BPD or histrionicity. So you see, it is not as simple as "organised" vs "disorganised", "sane" vs "insane", or "rape as power". Rape has many many motivations including power, sex, revenge, delusion, opportunity. Similarly it is not just psychopaths who rape. Fully half of all rapes are committed by people who have other psychological problems, or even no identifiable psychological problem at all. The results of the rape are also varied. Someone who is motivated by an inept desire for intercourse may end up killing the victim. Someone motivated by psychopathic predatory thoughts may only stalk their victim and never proceed to rape or sexual murder.

MTC:R3 - Towards a More Complex Model of Rape

I did lie. There was some significance to the multiplicity of categories. (Click for larger version) The Massachusetts Treatment Center Rapist typology, Version 3 (Knight & Prentky, 1990) This taxonomy (think species) of rapists is more nuanced and based on a larger set of data. Rather than relying on 4-6 unrelated categorisation, it incorporates underlying psychopathology, motive and the level of violent and/or sexual motivation that is behind these rapes. There is, then, an interesting distinction that comes about which I shall illustrate below: (Click for larger version) I have recoloured the diagram so that the level of red represents sexualisation and the level of yellow represents violence. In non-psychopathic sexual offenders, violence and sexualisation are inversely correlated- they range from red to yellow with only a very muted orange in-between. However, in psychopathic sexual offenders, violence and sexualisation are positively correlated- they are only various shades of orange. Note that this is true only for psychopathic RAPISTS, not for ALL psychopaths. Thus, perhaps in that minority of psychopaths who rape, violence and sex are much of the same emotion. This is in fact reinforced by the finding that while the VRAG (violent risk appraisal guide) which includes the PCL:R (the most common scale for measuring psychopathy) is a reasonable predictor for psychopathic rape and recidivism, an adjusted scale known as the SORAG (sex offending risk appraisal guide) which includes physical measurement of sexual arousal to sexual deviance in fact correlates with this criminal behaviour much better. And here we reach perhaps the crux of what I used to not understand about this crime. How such a thing could be done.

How could someone do this?

Some people do not know how to have sex, so they force it out of someone to get their way; they do not know much better. Some people are particularly angry and want to hurt and humiliate someone in particular and they know the effect that rape has; it is not about sex, it is about power and violence. Some people are just so horny and angry at the same time, or so turned on by domination and humilation that they plot and plan and find a victim to lash out at and fulfil their fantasies. And. Some people do it because there's someone right there and they just can, very easily- maybe just ignore that they're saying no or that they passed out or that they're drunk or drugged or happened to be there, pretend that it was the heat of the moment and they were really asking for it and how could someone stop themselves in that situation. I mean, you understand don't you? It's not like [person] would've ever been in that position if they didn't really want it, and you know how [person] is such a tease and they put me in this position where I just couldn't help myself. What are you gonna do in that situation? Just stop? I guess my point is that many people are apologists for the opportunity rapist and the date rapist. In fact, there are many who argue that it is not rape or that in that situation maybe they would do the same thing, or that the victim is to blame for the assault. Look at the underlying thought process and see its real meaning though:

"I raped because I could"

It is an abnormal thought process. It is in fact a psychopathic thought process. It is not the product of the usual human mind. The "I could not stop myself" and the "she was asking for it" are merely excuses and justifications for the true reason- "because I could".

Discussion

I believe that it is facile and simplistic to conclude that distinguishing particular patterns of rape means that some rapes (as defined above) are not rapes or that rape is a lesser crime according to motivation or psychopathology. The effect on the victim of the rape is dependent on many factors including the psychology of the victim- we do not claim that it is not a rape if the victim recovers better from the psychological trauma, so why should we claim that it is not a rape if the motivation for the rape was X, Y or Z? Sentencing is yet another issue and an altogether unrelated one. Sentencing takes into account societal impact, likelihood of recidivism and other factors- it is not and should not be interpreted purely as a measure of morality. It is a means by which society maintains social control, order, attempts to reduce the likelihood of crime and segregates the potential recidivist from potential future victims. Some rapists, stalkers, sexual murderers are far more amenable to rehabilitation than others. Some rehabilitation exercises do reduce recidivism and some do not. These factors are very important to find because of the following statistics:

• 50% of rapists re-offend in some way
• 50% do not
• Nearly all stalkers who harrass their victims have an associated psychiatric diagnosis- which may vary from frank schizophrenia/psychosis to an embedded personality disorder.
• Non-psychopathic offenders respond well to rehabilitation and therapy- some reoffend anyway but in significantly lower numbers
• Psychopathy as a personality trait has shown very little promise for treatment and psychotherapies used for non-psychopathic offenders in fact increase or have no effect on recidivism rate- but early research suggests psychopathic offenders may show lower recidivism rates as a result of punishment/behaviour based regimens

Thus, as a heterogenous group of people it is important that society does more research and action into finding appropriate stategies for managing these complex crimes. There is some suggestion that the gradually increasing sentence and taboo against rape has in fact led to a far lower rate of conviction for offenders than previously- someone is far more likely to plead guilty to a 2 year sentence than a 10 year one. Perhaps we should champion a graded system for rape and sexual assault- the first offence being 2 years and psychiatric evaluation, treatment and rehabilitation. The 2nd offence, 5 years with treatment and close community monitoring, the 3rd 10 years with treatment and very intensive community monitoring. First time offenders would be more likely to admit to their crime and all would undergo measures to attempt to rehabilitate them. However the punishment would increase with each subsequent offence- and remember it is much easier to reconvict someone than to convict someone on a first time offence. Accordingly there should be close surveillance of this vulnerable group to lessen the risk of re-offending. With stalking, the psychiatric diagnosis is paramount; some stalkers are experiencing a frank psychotic episode and requite psychiatric hospitalisation and treatment. Others may be motivated by a personality disorder such as borderline personality or psychopathy. Depending on what this is, treatment and punishment should proceed accordingly.

Conclusion

Rape and stalking are common crimes affecting a large percentage of the population. They are also under-reported crimes. Thus it is highly likely if not definitely true that we all know someone who has been raped, stalked or both. Even if the number of perpetrators is low - this would imply a high re-offending rate, consistent with the data. Not only are these crimes common, but their incidence far outweighs the likelihood of a false report. False reports no doubt happen and it is very unfortunate and vindictive if they do so; however such events are very rare indeed and far more common is true rape, stalking and sexual assault. Rapists and stalkers both commit their crimes for a variety of reasons, sexual, violent or both. These reasons include desire for intimacy, revenge/retaliation, sexual fetishism and pure opportunity. Both rapists and stalkers have a high rate of recidivism and co-existing psychiatric diagnosis, whether it be psychotic, mood-related or personality disorder including psychopathy. They are a complex group of criminals with varying motivations and modes of activity but this makes their crimes no less wrong. Similarly, victims range from young women of reproductive age to babies to old women to old men to young men and anywhere in between. This variability indeed highlights the fact that no victim of rape or stalking is deservent of the crime but is in fact a "convenient object" for the commission of the crime. If it were not them, it would be someone else, so to speak. It is important that we recognise that these crimes do happen to people we know and are far more common than we realise. It is also very important not to blame the victim and to realise that most of the perpetrators are mentally ill individuals who require psychiatric treatment, rehabilitation and/or even segregation from the greater community.