discussion

PERSONALITY DISORDER IS DISEASE

DAVID P. AUSUBEL

Bureau of Educational Research, University of Illinois

IN two recent articles in the American Psycholo- gist, Szasz (1960) and Mowrer (1960) have argued the case for discarding the concept of

mental illness. The essence of Mowrer's position is that since medical science lacks "demonstrated competence . . . in psychiatry," psychology would be wise to "get out" from "under the penumbra of medicine," and to regard the behavior disorders as manifestations of sin rather than of disease (p. 302). Szasz' position, as we shall see shortly, is somewhat more complex than Mowrer's, but agrees with the latter in emphasizing the moral as op- posed to the psychopathological basis of abnormal behavior.

For a long time now, clinical psychology has both repudiated the relevance of moral judgment and accountability for assessing behavioral acts and choices, and has chafed under medical (psychiatric) control and authority in diagnosing and treating the personality disorders. One can readily appreci- ate, therefore, Mowrer's eagerness to sever the historical and professional ties that bind clinical psychology to medicine, even if this means denying that psychological disturbances constitute a form of illness, and even if psychology's close working relationship with psychiatry must be replaced by a new rapprochement with sin and theology, as "the lesser of two evils" (pp. 302-303). One can also sympathize with Mowrer's and Szasz' dissatisfac- tion with prevailing amoral and nonjudgmental trends in clinical psychology and with their entirely commendable efforts to restore moral judgment and accountability to a respectable place among the criteria used in evaluating human behavior, both normal and abnormal.

Opposition to these two trends in the handling of the behavior disorders (i.e., to medical control and to nonjudgmental therapeutic attitudes), how- ever, does not necessarily imply abandonment of the concept of mental illness. There is no incon- sistency whatsoever in maintaining, on the one hand, that most purposeful human activity has a moral aspect the reality of which psychologists cannot afford to ignore (Austibel, 1952, p. 462),

that man is morally accountable for the majority of his misdeeds (Ausubel, 1952, p. 469), and that psychological rather than medical training and sophistication are basic to competence in the per- sonality disorders (Ausubel, 1956, p. 101), and affirming, on the other hand, that the latter dis- orders are genuine manifestations of illness. In recent years psychology has been steadily moving away from the formerly fashionable stance of ethical neutrality in the behavioral sciences; and in spite of strident medical claims regarding superior professional qualifications and preclusive legal re- sponsibility for treating psychiatric patients, and notwithstanding the nominally restrictive provisions of medical practice acts, clinical psychologists have been assuming an increasingly more important, independent, and responsible role in treating the mentally ill population of the United States.

It would be instructive at this point to examine the tactics of certain other medically allied profes- sions in freeing themselves from medical control and in acquiring independent, legally recognized professional status. In no instance have they resorted to the devious stratagem of denying that they were treating diseases, in the hope of mollify- ing medical opposition and legitimizing their own professional activities. They took the position in- stead that simply because a given condition is de- nned as a disease, its treatment need not necessarily be turned over to doctors of medicine if other equally competent professional specialists were available. That this position is legally and politi- cally tenable is demonstrated by the fact that an impressively large number of recognized diseases are legally treated today by both medical and non- medical specialists (e.g., diseases of the mouth, face, jaws, teeth, eyes, and feet). And there are few convincing reasons for believing that psychiatrists wield that much more political power than physi- cians, maxillofacial surgeons, ophthalmologists, and orthopedic surgeons, that they could be successful where these latter specialists have failed, in legally restricting practice in their particular area of com- petence to holders of the medical degree. Hence,

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even if psychologists were not currently managing to hold their own vis-a-vis psychiatrists, it would be far less dangerous and much more forthright to press for the necessary ameliorative legislation than to seek cover behind an outmoded and thoroughly discredited conception of the behavior disorders.

THE SZASZ-MOWRER POSITION

Szasz' (1960) contention that the concept of mental illness "now functions merely as a conven- ient myth" (p. 118) is grounded on four unsub- stantiated and logically untenable propositions, which can be fairly summarized as follows:

1. Only symptoms resulting from demonstrable physical lesions qualify as legitimate manifestations of disease. Brain pathology is a type of physical lesion, but its symptoms properly speaking, are neurological rather than psychological in nature. Under no circumstances, therefore, can mental symptoms be considered a form of illness.

2. A basic dichotomy exists between mental symptoms, on the one hand, which are subjective in nature, dependent on subjective judgment and personal involvement of the observer, and referable to cultural-ethical norms, and physical symptoms, on the other hand, which are allegedly objective in nature, ascertainable without personal involvement of the observer, and independent of cultural norms and ethical standards. Only symptoms possessing the latter set of characteristics are genuinely reflec- tive of illness and amenable to medical treatment.

3. Mental symptoms are merely expressions of problems of living and, hence, cannot be regarded as manifestations of a pathological condition. The concept of mental illness is misleading and demon- ological because it seeks to explain psychological disturbance in particular and human disharmony in general in terms of a metaphorical but nonexistent disease entity, instead of attributing them to inher- ent difficulties in coming to grips with elusive problems of choice and responsibility.

4. Personality disorders, therefore, can be most fruitfully conceptualized as products of moral conflict, confusion, and aberration. Mowrer (1960) extends this latter proposition to include the dictum that psychiatric symptoms are primarily reflective of unacknowledged sin, and that individuals mani- festing these symptoms are responsible for and deserve their suffering, both because of their original

transgressions and because they refuse to avow and expiate their guilt (pp. 301, 304).

Widespread adoption of the Szasz-Mowrer view of the personality disorders would, in my opinion, turn back the psychiatric clock twenty-five hundred years. The most significant and perhaps the only real advance registered by mankind in evolving a rational and humane method of handling behavioral aberrations has been in substituting a concept of disease for the demonological and retributional doc- trines regarding their nature and etiology that flourished until comparatively recent times. Con- ceptualized as illness, the symptoms of personality disorders can be interpreted in the light of under- lying stresses and resistances, both genie and en- vironmental, and can be evaluated in relation to specifiable quantitative and qualitative norms of appropriately adaptive behavior, both cross-cultur- ally and within a particular cultural context. It would behoove us, therefore, before we abandon the concept of mental illness and return to the medieval doctrine of unexpiated sin or adopt Szasz' ambigu- ous criterion of difficulty in ethical choice and responsibility, to subject the foregoing propositions to careful and detailed study.

Mental Symptoms and Brain Pathology

Although I agree with Szasz in rejecting the doc- trine that ultimately some neuroanatomic or neuro- physiologic defect will be discovered in all cases of personality disorder, I disagree with his reasons for not accepting this proposition.. Notwithstanding Szasz' straw man presentation of their position, the proponents of the extreme somatic view do not really assert that the particular nature of a patient's disordered beliefs can be correlated with "certain definite lesions in the nervous system" (Szasz, 1960, p. 113). They hold rather that normal cognitive and behavioral functioning depends on the anatomic and physiologic integrity of certain key areas of the brain, and that impairment of this substrate integrity, therefore, provides a physical basis for disturbed ideation and behavior, but does not ex- plain, except in a very gross way, the particular kinds of symptoms involved. In fact, they are generally inclined to attribute the specific character of the patient's symptoms to the nature of his pre- illness personality structure, the substrate integrity of which is impaired by the lesion or metabolic defect in question.

PERSONALITY DISORDER Is DISEASE 71

Nevertheless, even though this type of reasoning plausibly accounts for the psychological symptoms found in general paresis, various toxic deleria, and other comparable conditions, it is an extremely im- probable explanation of all instances of personality disorder. Unlike the tissues of any other organ, brain tissue possesses the unique property of making possible awareness of and adjustment to the world of sensory, social, and symbolic stimulation. Hence by virtue of this unique relationship of the nervous system to the environment, diseases of behavior and personality may reflect abnormalities in personal and social adjustment, quite apart from any struc- tural or metabolic disturbance in the underlying neural substrate. I would conclude, therefore, that although brain pathology is probably not the most important cause of behavior disorder, it is un- doubtedly responsible for the incidence of some psychological abnormalities as well as for various neurological signs and symptoms.

But even if we completely accepted Szasz' view that brain pathology does not account for any symptoms of personality disorder, it would still be unnecessary to accept his assertion that to qualify as a genuine manifestation of disease a given symptom must be caused by a physical lesion. Adoption of such a criterion would be arbitrary and inconsistent both with medical and lay connotations of the term "disease," which in current usage is generally regarded as including any marked devia- tion, physical, mental, or behavioral, from normally desirable standards of structural and functional integrity.

Mental versus Physical Symptoms

Szasz contends that since the analogy between physical and mental symptoms is patently fal- lacious, the postulated parallelism between physical and mental disease is logically untenable. This line of reasoning is based on the assumption that the two categories of symptoms can be sharply dichotomized with respect to such basic dimensions as objectivity-subjectivity, the relevance of cultural norms, and the need for personal involvement of the observer. In my opinion, the existence of such a dichotomy cannot be empirically demonstrated in convincing fashion.

Practically all symptoms of bodily disease involve some elements of subjective judgment—both on the part of the patient and of the physician. Pain is perhaps the most important and commonly used

criterion of physical illness. Yet, any evaluation of its reported locus, intensity, character, and dura- tion is dependent upon the patient's subjective appraisal of his own sensations and on the physi- cian's assessment of the latter's pain threshold, intelligence, and personality structure. It is also a medical commonplace that the severity of pain in most instances of bodily illness may be mitigated by the administration of a placebo. Furthermore, in taking a meaningful history the physician must not only serve as a participant observer but also as a skilled interpreter of human behavior. It is the rare patient who does not react psychologically to the signs of physical illness; and hence physicians are constantly called upon to decide, for example, to what extent precordial pain and reported tight- ness in the chest are manifestations of coronary insufficiency, of fear of cardiac disease and impend- ing death, or of combinations of both conditions. Even such allegedly objective signs as pulse rate, BMR, blood pressure, and blood cholesterol have their subjective and relativistic aspects. Pulse rate and blood pressure are notoriously susceptible to emotional influences, and BMR and blood choles- terol fluctuate widely from one cultural environment to another (Dreyfuss & Czaczkes, 1959). And anyone who believes that ethical norms have no relevance for physical illness has obviously failed to consider the problems confronting Catholic pa- tients and/or physicians when issues of contracep- tion, abortion, and preferential saving of the mother's as against the fetus' life must be faced in the context of various obstetrical emergencies and medical contraindications to pregnancy.

It should now be clear, therefore, that symptoms not only do not need a physical basis to qualify as manifestations of illness, but also that the evalua- tion of all symptoms, physical as well as mental, is dependent in large measure on subjective judg- ment, emotional factors, cultural-ethical norms, and personal involvement on the part of the observer. These considerations alone render no longer tenable Szasz' contention (1960, p. 114) that there is an inherent contradiction between using cultural and ethical norms as criteria of mental disease, on the one hand, and of employing medical measures of treatment on the other. But even if the postulated dichotomy between mental and physical symptoms were valid, the use of physical measures in treat- ing subjective and relativisitic psychological symp- toms would still be warranted. Once we accept the

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proposition that impairment of the neutral substrate of personality can result in behavior disorder, it is logically consistent to accept the corollary proposi- tion that other kinds of manipulation of the same neutral substrate can conceivably have therapeutic effects, irrespective of whether the underlying cause of the mental symptoms is physical or psychological.

Mental Illness and Problems of Living

"The phenomena now called mental illness," argues Szasz (1960), can be regarded more forth- rightly and simply as "expressions of man's struggle with the problem of how he should live" (p. 117). This statement undoubtedly oversimplifies the nature of personality disorders; but even if it were adequately inclusive it would not be inconsistent with the position that these disorders are a mani- festation of illness. There is no valid reason why a particular symptom cannot both reflect a problem in living and constitute a manifestation of disease. The notion of mental illness, conceived in this way, would not "obscure the everyday fact that life for most people is a continuous struggle . . . for a 'place in the sun,' 'peace of mind,' or some other human value" (p. 118). It is quite true, as Szasz points out, that "human relations are inherently fraught with difficulties" (p. 117), and that most people manage to cope with such difficulties without becoming mentally ill. But conceding this fact hardly precludes the possibility that some indi- viduals, either because of the magnitude of the stress involved, or because of genically or environ- mentally induced susceptibility to ordinary degrees of stress, respond to the problems of living with behavior that is either seriously distorted or suf- ficiently unadaptive to prevent normal interpersonal relations and vocational functioning. The latter outcome—gross deviation from a designated range of desirable behavioral variability—conforms to the generally understood meaning of mental illness.

The plausibility of subsuming abnormal be- havioral reactions to stress under the general rubric of disease is further enhanced by the fact that these reactions include the same three principal categories of symptoms found in physical illness. Depression and catastrophic impairment of self- esteem, for example, are manifestations of person- ality disorder which are symptomologically com- parable to edema in cardiac failure or to heart murmurs in valvular disease. They are indicative of underlying pathology but are neither adaptive

nor adjustive. Symptoms such as hypomanic over- activity and compulsive striving toward unrealisti- cally high achievement goals, on the other hand, are both adaptive and adjustive, and constitute a type of compensatory response to basic feelings of inadequacy, which is not unlike cardiac hyper- trophy in hypertensive heart disease or elevated white blood cell count in acute infections. And finally, distortive psychological defenses that have some adjustive value but are generally maladaptive (e.g., phobias, delusions, autistic fantasies) are analogous to the pathological situation found in conditions like pneumonia, in which the excessive outpouring of serum and phagocytes in defensive response to pathogenic bacteria literally causes the patient to drown in his own fluids.

Within the context of this same general proposi- tion, Szasz repudiates the concept of mental illness as demonological in nature, i.e., as the "true heir to religious myths in general and to the belief in witchcraft in particular" (p. 118) because it al- legedly employs a reined abstraction ("a deformity of personality") to account in causal terms both for "human disharmony" and for symptoms of behavior disorder (p. 114). But again he appears to be demolishing a straw man. Modern students of personality disorder do not regard mental illness as a cause of human disharmony, but as a co- manifestation with it of inherent difficulties in personal adjustment and interpersonal relations; and in so far as I can accurately interpret the literature, psychopathologists do not conceive of mental illness as a cause of particular behavioral symptoms but as a generic term under which these symptoms can be subsumed.

Mental Illness and Moral Responsibility

Szasz' final reason for regarding mental illness as a myth is really a corollary of his previously considered more general proposition that mental symptoms are essentially reflective of problems of living and hence do not legitimately qualify as manifestations of disease. It focuses on difficulties of ethical choice and responsibility as the particular life problems most likely to be productive of per- sonality disorder. Mowrer (1960) further extends this corollary by asserting that neurotic and psy- chotic individuals are responsible for their suffer- ing (p. 301), and that unacknowledged and un- expiated sin, in turn, is the basic cause of this suffering (p. 304). As previously suggested, how-

PERSONALITY DISORDER fs DISEASE 73

ever, one can plausibly accept the proposition that psychiatrists and clinical psychologists have erred in trying to divorce behavioral evaluation from ethical considerations, in conducting psychotherapy in an amoral setting, and in confusing the psychological explanation of unethical behavior with absolution from accountability for same, without necessarily endorsing the view that personality disorders are basically a reflection of sin, and that victims of these disorders are less ill than responsible for their symptoms (Ausubel, 1952, pp. 392-397, 465- 471).

In the first place, it is possible in most instances (although admittedly difficult in some) to distin- guish quite unambiguously between mental illness and ordinary cases of immorality. The vast majority of persons who are guilty of moral lapses knowingly violate their own ethical precepts for expediential reasons—despite being volitionally capable at the time, both of choosing the more moral alternative and of exercising the necessary inhibitory control (Ausubel, 1952, pp. 465-471). Such persons, also, usually do not exhibit any signs of behavior disorder. At crucial choice points in facing the problems of living they simply choose the opportunistic instead of the moral alternative. They are not mentally ill, but they are clearly accountable for their misconduct. Hence, since personality disorder and immorality are neither coextensive nor mutually exclusive conditions, the concept of mental illness need not necessarily obscure the issue of moral accountability.

Second, guilt may be a contributory factor in behavior disorder, but is by no means the only or principal cause thereof. Feelings of guilt may give rise to anxiety and depression; but in the absence of catastrophic impairment of self-esteem induced by other factors, these symptoms tend to be transi- tory and peripheral in nature (Ausubel, 1952, pp. 362-363). Repression of guilt, is more a conse- quence than a cause of anxiety. Guilt is repressed in order to avoid the anxiety producing trauma to self-esteem that would otherwise result if it were acknowledged. Repression per se enters the causal picture in anxiety only secondarily—by obviating "the possibility of punishment, confession, expia- tion, and other guilt reduction mechanisms" (Ausubel, 1952, p. 456). Furthermore, in most types of personality disorder other than anxiety, depression, and various complications of anxiety such as phobias, obsessions, and compulsion, guilt

feelings are either not particularly prominent (schizophrenic reactions), or are conspicuously absent (e.g., classical cases of inadequate or ag- gressive, antisocial psychopathy).

Third, it is just as unreasonable to hold an individual responsible for symptoms of behavior disorder as to deem him accountable for symptoms of physical illness. He is no more culpable for his inability to cope with sociopsychological stress than he would be for his inability to resist the spread of infectious organisms. In those instances where warranted guilt feelings do contribute to personality disorder, the patient is accountable for the mis- deeds underlying his guilt, but is hardly responsible for the symptoms brought on by the guilt feelings or for unlawful acts committed during his illness. Acknowledgment of guilt may be therapeutically beneficial under these circumstances, but punish- ment for the original misconduct should obviously be deferred until after recovery.

Lastly, even if it were true that all personality disorder is a reflection of sin and that people are accountable for their behavioral symptoms, it would still be unnecessary to deny that these symptoms are manifestations of disease. Illness is no less real because the victim happens to be culpable for his illness. A glutton with hypertensive heart disease undoubtedly aggravates his condition by overeat- ing, and is culpable in part for the often fatal symptoms of his disease, but what reasonable person would claim that for this reason he is not really ill?

CONCLUSIONS

P'our propositions in support of the argument for discarding the concept of mental illness were carefully examined, and the following conclusions were reached:

First, although brain pathology is probably not the major cause of personality disorder, it does account for some psychological symptoms by im- pairing the neural substrate of personality. In any case, however, a symptom need not reflect a physical lesion in order to qualify as a genuine manifestation of disease.

Second, S/asz' postulated dichotomy between mental and physical symptoms is untenable because the assessment of all symptoms is dependent to some extent on subjective judgment, emotional factors, cultural-ethical norms, and personal involvement of the observer. Furthermore, the use of medical

AMERICAN PSYCHOLOGIST

measures in treating behavior disorders- -irrespec- tive of whether the underlying causes are neural or psychological—is defensible on the grounds that if inadvertent impairment of the neural substrate of personality can have distortive effects on be- havior, directed manipulation of the same substrate may have therapeutic effects.

Third, there is no inherent contradiction in re- garding mental symptoms both as expressions of problems in living and as manifestations of illness. The latter situation results when individuals are for various reasons unable to cope with such prob- lems, and react with seriously distorted or mal- adaptive behavior. The three principal categories of behavioral symptoms—manifestations of im- paired functioning, adaptive compensation, and de- fensive overreaction—are also found in bodily disease. The concept of mental illness has never been advanced as a demonological cause of human disharmony, but only as a co-manifestation with it of certain inescapable difficulties and hazards in personal and social adjustment. The same concept is also generally accepted as a generic term for all behavioral symptoms rather than as a reified cause of these symptoms.

Fourth, the view that personality disorder is less a manifestation of illness than of sin, i.e., of culpable inadequacy in meeting problems of ethical choice and responsibility, and that victims of be- havior disorder are therefore morally accountable for their symptoms, is neither logically nor empiri- cally tenable. In most instances immoral behavior and mental illness are clearly distinguishable con- ditions. Guilt is only a secondary etiological factor in anxiety and depression, and in other personality disorders is either not prominent or conspicuously absent. The issue of culpability for symptoms is

largely irrelevant in handling the behavior disorders, and in any case docs not detract from the reality of the illness.

In general, it is both unnecessary and potentially dangerous to discard the concept of mental illness on the grounds that only in this way can clinical psychology escape from the professional domination of medicine. Dentists, podiatrists, optometrists, and osteopaths have managed to acquire an independent professional status without rejecting the concept of disease. It is equally unnecessary and dangerous to substitute the doctrine of sin for illness in order to counteract prevailing amoral and nonjudgmental trends in psychotherapy. The hypothesis of re- pressed guilt does not adequately explain most kinds and instances of personality disorder, and the concept of mental illness does not preclude judg- ments of moral accountability where warranted. Definition of behavior disorder in terms of sin or of difficulties associated with ethical choice and responsibility would substitute theological disputa- tion and philosophical wrangling about values for specifiable quantitative and qualitative criteria of disease.

REFERENCES

AUSUBW,, D. P. Ego development and the personality dis- orders. New York: Grunc & Straiten, 1952.

AtrsuBEt, D. P. Relationships between psychology and psychiatry: The hidden issues. Amer. Psychologist, 1956, 11, 99-105.

DREYEUSS, F., & CZACZKES, J. W. Blood cholesterol and uric acid of healthy medical students under the stress of an examination. AMA Arch, intern. Med., 1959, 103, 708.

MOWRER, O. H. "Sin," the lesser of two evils. Amer. Psychologist, 1960, 15, 301-304.

SZASZ, T. S. The myth of mental illness. Amer. Psycholo- gist 1960, 15, 113-118.