moral disorder in the dsm-iv?: the cluster b personality ......define the cluster b personality...

Moral Disorder In the DSM-IV?: The Cluster B Personality Disorders

Marga Reimer

Philosophy, Psychiatry, & Psychology, Volume 20, Number 3, September2013, pp. 203-215 (Article)

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Moral Disorder In the DSM-IV? The Cluster B

Personality Disorders

Marga Reimer

Abstract: Psychiatry has often been accused of ‘medi-calizing morals.’ The DSM-IV’s inclusion of the Cluster B Personality Disorders (Antisocial, Borderline, Histri-onic, and Narcissistic) might seem to lend credence to this charge. Bioethicist Louis Charland and physician-philosopher Carl Elliott would likely concur. Whereas Charland argues that the Cluster B disorders are ‘moral rather than medical’ conditions, that they are genuine ‘illnesses’ is an idea that, according to Elliott, ‘should give us pause.’ Although the intuitions captured in the arguments of Charland and Elliott are undeniably strong, the arguments themselves are rather weak. In responding to these arguments, I defend the view that the Cluster B Personality Disorders are ‘fundamentally mental’ and only ‘contingently moral.’ They are genuine mental disorders, rightly included in the DSM, whose symptoms consist largely of morally disvalued traits.

Keywords: medicalization of morals, mental disorder, Louis Charland, Carl Elliott

The DSM professes to be a manual for the diagnosis of mental disorders. It is, moreover, published by a medical associa-tion, the American Psychiatric Association (APA). Knowing only this, one might be surprised to learn that the most recent edition of that manual (DSM-IV-TR) includes a section on ‘Personality Disorders,’ some of which are defined almost ex-clusively in terms of deviations from moral norms.

These are the so-called ‘Cluster B’ Personality Disorders of which there are four: Antisocial, Borderline, Histrionic, and Narcissistic. Given the diagnostic criteria associated with these disorders, one might naturally wonder: What are they doing in a medical manual for the diagnosis of mental disorders? Just consider some of the traits featured in the associated diagnostic criteria. They include:

reckless disregard for safety of self or others; inappropri-ate, intense anger or difficulty controlling anger; uncom-fortable in situations in which [they are] not the center of attention; sense of entitlement. (APA 2000, 701–17)

These traits seem more suggestive of character flaws, of ‘moral disorder,’ than of mental disor-der. Is it possible that the Cluster B Personality Disorders are, in fact, moral rather than mental disorders? Is their inclusion in the DSM simply an instance, and a rather blatant one, of the ‘medi-calization of morals’?

My aim in what follows is to address these concerns. I do this by way of a close examina-tion of several intuitively powerful arguments for the moral/non-medical nature of the Cluster B Personality Disorders. In responding to these arguments, I defend an alternative view, which I take to be the view embodied in the DSM, the view of mainstream American psychiatry. According to this view, the Cluster B Personality Disorders

204 ■ PPP / Vol. 20, No. 3 / September 2013

might be characterized as ‘fundamentally mental’ and only ‘contingently moral.’ They are (more particularly) genuine mental disorders, the signs and symptoms of which consist largely of morally disvalued traits.1 I conclude with a brief discussion of the implications, practical as well as theoretical, of such a view.

I am going to consider three arguments for the moral/non-medical nature of the disorders in ques-tion: two proposed by bioethicist Louis Charland (2004, 2006) and one suggested by physician-philosopher Carl Elliott (1996). However, before having a look at these arguments, a few termino-logical matters need to be clarified. I am construing the core issue in terms of whether the Cluster B Personality Disorders are ‘moral disorders’ rather than ‘mental disorders.’ As I employ the notion, ‘mental disorders’ are conditions appropriately diagnosed and treated by contemporary psychia-trists and clinical psychologists. In essence, they are conditions rightly included in today’s profes-sional manuals for the diagnosis of psychiatric disorders, manuals like the DSM.

Elliott, like Charland in the earlier of his two papers, contrasts the Cluster B disorders (and the DSM Personality Disorders more generally), not with specifically mental disorders, but with medi-cal conditions, with ‘illnesses.’ By talking in terms of illnesses, Elliott presumably means to signify conditions appropriately diagnosed and treated by medical professionals, including psychiatrists. In the later of his two papers, Charland contrasts the Cluster B disorders not with medical conditions, but rather with the broader category of ‘clinical’ conditions. Presumably, this terminological shift is meant to reflect the idea that clinical psychologists, as well as psychiatrists, are trained in the diagnosis and treatment of mental disorders.

The key point is this. The difference between a ‘fundamentally mental, contingently moral’ view of the Cluster B disorders and the views of Charland (‘moral not medical/clinical’) and Elliott (‘not medical’) is substantive, rather than merely terminological. Both Charland and Elliott question the idea that the Cluster B Personality Disorders are ‘mental disorders’ in the sense in which I employ that notion. I am inclined (for reasons detailed below) to view those conditions

as appropriately diagnosed and treated by con-temporary psychiatrists and clinical psychologists. Charland is not so inclined—not unless these mental health professionals also happen to be trained in the sort of ‘moral therapy’ essential (according to Charland) for successful treatment of the Cluster B disorders.2 Elliott, like Charland, questions the idea that the Cluster B disorders are genuine illnesses, appropriately treated by medical professionals, including psychiatrists. I do not. I do, however, prefer to think of those conditions as ‘disorders’ rather than as “illnesses.” For they are not always (or even generally) associated with the sort of subjective distress or discomfort so strongly conveyed by the notion of illness. (For details, see ‘The Argument from Illness’ below.)

Let’s now turn to the arguments in question, beginning with Charland’s ‘argument from iden-tification.’

The Argument From Identification (Charland 2006)

According to this argument, given the current DSM diagnostic criteria, identification of the Clus-ter B Personality Disorders is not possible without the “explicit use of [primarily] moral terms and notions” (Charland 2006, 119). Those disorders are therefore (presumptively) moral rather than mental (medical/clinical) disorders.3

Charland’s ‘argument from identification’ captures the folk (vs. theoretical or professional) intuition that the Cluster B diagnostic criteria amount to nothing more than a laundry list of character flaws. That the list appears in a puta-tively ‘medical’ manual for the diagnosis of mental disorders does little to diminish the strength of the intuition. It simply proves (so one might think) that mainstream American psychiatry is indeed guilty of ‘medicalizing morals.’

Despite the strength of the intuition, the argu-ment that articulates it is problematic. Although its single premise is incontestable,4 the inference from premise to conclusion is weak. This weak-ness can be brought out directly by questioning the underlying assumption that disorders whose identification requires the “explicit use of [primar-

Reimer / Moral Disorder in DSM-IV ■ 205

ily] moral terms and notions” are moral rather than mental disorders. It can also be brought out indirectly by constructing and critiquing a parallel, and more patently weak, argument for the ‘social’ (vs. mental) nature of the other DSM Personal-ity Disorders, the Cluster A and C Personality Disorders. Let’s begin with a direct critique of Charland’s argument.

Direct CritiqueAlthough the proper analysis of ‘mental dis-

order’ is much disputed among philosophers, psychiatrists, and psychologists (Stein et al. 2010), the current DSM characterization of the phenomenon represents the consensus, insofar as there is one, of one prominent body of experts: mainstream American psychiatry.5 So let’s turn to that characterization and ask whether there is any tension in claiming of a particular condition, whose identification requires the “explicit use of [primarily] moral terms and notions” (Charland 2006, 119) that it is a mental disorder. According to the most recent edition of the DSM, a ‘mental disorder’ is,

a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a be-havioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, reli-gious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction in the individual, as described above. (APA 2000, xxxi)

There is no question that the foregoing stands in need of some clarification and general tightening up (Stein et al. 2010). There is equally no question that several recently proposed revisions (Stein et al. 2010) are problematic even if they do represent genuine improvements (First and Wakefield 2010; Verhoeff and Glas 2010). However, the question here is only with whether there is any tension in the

idea that conditions whose identification requires the “explicit use of [primarily] moral terms and notions” (Charland 2006, 119), might satisfy the current, admittedly imperfect, DSM characteriza-tion of ‘mental disorder.’

There seems to be no such tension. Indeed, it is natural to suppose that satisfaction of any of the Cluster B diagnostic criteria would coincide with satisfaction of the current DSM criteria for mental disorder. After all, deviations from moral norms, when chronic, are likely to be ‘associated with’ (whether as presumptive causes of, or significant risk factors for) such things as distress, disability, death, and loss of freedom. A man with Antisocial Personality Disorder ends up dead at age 25, killed by a rival drug dealer. A woman with Borderline Personality Disorder must rely on disability ben-efits, because her condition makes workplace collegiality impossible. A second woman, meeting the criteria for Histrionic Personality Disorder, becomes clinically depressed after her status as one of Hollywood’s ‘leading ladies’ begins to decline. A man with Narcissistic Personality Disorder, a brilliant mathematician with the potential to do revolutionary work, is unable to realize that po-tential, having been rejected by the only graduate program to which he applied (Harvard’s). The point here is a simple one: chronic (and sometimes flagrant) violations of moral norms of the sort that define the Cluster B Personality Disorders might well be ‘associated with’ the undesirable condi-tions (distress, disability, death, loss of freedom) specified in the DSM criteria for ‘mental disorder’ (Reimer 2010a).

It might be countered that such ‘association’ does not guarantee satisfaction of the DSM criteria for mental disorder. For a disorder to be a DSM ‘mental disorder,’ it must also be a “manifesta-tion of a behavioral, psychological, or biological dysfunction in the individual” (APA 2000, xxxi). One might reasonably wonder whether the Clus-ter B Personality Disorders satisfy this further condition. Perhaps they are simply amalgama-tions of those moral shortcomings that tend to be associated with distress, disability, death, and loss of freedom. In that case, perhaps they are manifestations of distinctively moral (vs. behav-ioral, psychological, or biological) ‘dysfunction in


the individual.’ Charland seems to anticipate this point when he claims that, although the Cluster B disorders “may cause clinical distress,” that is “hardly sufficient to consider a disorder clinical in nature and, therefore, subject to and amenable to clinical treatment and therapy” (Charland 2006, 120).

In response, I would point out that association with distress, disability, death, and loss of freedom is at least suggestive of DSM ‘dysfunction in the individual.’ In the case of the Cluster B disorders, such dysfunction would seem to be behavioral as well as psychological. It is, after all, the chronically antisocial actions and attitudes of the Cluster B patient that arguably lead to distress, disability, death, and loss of freedom. (This is not, of course, to deny that such actions and attitudes involve deviations from moral norms.) Moreover, recent experimental data point to neurobiological dys-function in two of the four Cluster B Personality Disorders: Antisocial and Borderline (Oldham 2005). Patients with both disorders demonstrate serotonin dysfunction in connection with impul-sive aggression. Additionally, those with Antisocial Personality Disorder show decreased prefrontal gray matter volume and increased white matter volume in the corpus callosum, a finding that may help to explain deficits in affect control and decision making (Oldham 2005). Such data are suggestive of dysfunction that is, quite literally, ‘in’ the individual. The DSM criterion of ‘dysfunction in the individual’ might thus seem to be satisfied three times over, because the disorders in question are arguably ‘manifestations of’ behavioral, psy-chological, and (in at least some cases) biological dysfunction in the individual.6

Although Charland claims (2006, 120) that the DSM provides no “clinical reason or evidence to think that the Cluster B disorders are more than moral categories,” one might question that claim on the grounds that satisfaction of the associated diagnostic criteria arguably coincides with satis-faction of the DSM criteria for ‘mental disorder.’ Indeed, it is just this envisioned (and clinically informed) coincidence that explains, and to some extent justifies, the inclusion of the Cluster B Personality Disorders in the DSM in the first place (APA 2000, xxxi). One might also question

Charland’s claim on the grounds that not all of the traits specified in the current diagnostic criteria for the Cluster B disorders are clearly “moral” (vs. “clinical”; Pickard 2009, 93).

In sum, Charland’s argument from identifica-tion does not seem to provide much support for his claim that the Cluster B Personality Disorders are moral rather than mental (medical, clinical) disorders. However, perhaps the argument could be made more credible were its conclusion changed to the more modest one that the Cluster B Per-sonality Disorders have moral ‘aspects.’ Such a conclusion would leave open the possibility that those disorders have ‘clinical’ aspects as well, aspects that might be made explicit in future edi-tions of the DSM. This is a possibility to which Charland seems open (2006, 120). However, given the current DSM diagnostic criteria for the Cluster B disorders, Charland’s view is that those disorders emerge as thoroughly moral in nature, notwith-standing their frequent comorbidity with clinical conditions such as depression and anxiety. The above critique is intended to challenge that view.

Indirect CritiqueLet’s now turn to an indirect critique of Char-

land’s argument from identification. As mentioned above, we can critique the argument indirectly by constructing and critiquing a parallel argument for the view that the Cluster A and C Personal-ity Disorders are ‘social’ rather than ‘mental’ disorders. One might think of a ‘social disorder,’ roughly, as an undesirable condition characterized by a chronic failure to conform to social norms (whether psychological or behavioral) that are not distinctively moral.

Let’s begin by taking a quick look at the dis-orders and their associated diagnostic criteria. The Personality Disorders in Cluster A include Paranoid, Schizoid, and Schizotypal; these three disorders are collectively characterized as ‘odd or eccentric.’ The Personality Disorders in Cluster C include Avoidant, Dependent, and Obsessive-Compulsive; these three disorders are collectively characterized as ‘anxious or fearful.’ (The disor-ders in Cluster B are collectively characterized as ‘dramatic, emotional, or erratic.’)


Both the Cluster A and Cluster C Personality Disorders are defined largely by deviations from social norms that are not distinctively moral. Traits featured in the diagnostic criteria for the Cluster A disorders include:

reads hidden demeaning or threatening meanings into benign remarks or events; almost always chooses soli-tary activities; behavior or appearance is odd, eccentric, or peculiar. (APA 2000, 690–701)

Traits featured in the diagnostic criteria for the Cluster C disorders include:

is unwilling to get involved with people unless certain of being liked; needs others to assume responsibility for most major areas of his or her life; shows rigidity and stubbornness. (APA 2000, 718–29)

Consider now the following argument for the social (vs. mental) nature of the Cluster A and C Personality Disorders, one that parallels Char-land’s argument for the moral (vs. mental) nature of the Cluster B Personality Disorders:

given the current DSM diagnostic criteria, identification of the Cluster A and C Personality Disorders is not pos-sible without the explicit use of primarily social terms and notions (such as ‘odd,’ ‘eccentric,’ ‘rigid,’ and ‘stub-born’). Those disorders are therefore (presumptively) social rather than mental (medical/clinical) disorders.

Before commenting on the strength of this argu-ment, it is interesting to note that its conclusion is one that Charland seems to question. As he writes in his (2010, 120) commentary on Zachar and Potter (2010),

I explicitly state that the Cluster A and C personality disorders may actually be genuine medical kinds, with few or no moral dimensions. . . . So nowhere do I say or mean to suggest that all the personality disorders are moral rather than medical kinds. Strictly speaking, my conclusion applies to the Cluster B personality disorders only and not to personality disorders as a whole.

My concern is not with Charland’s suggestion that the Cluster A and C Personality Disorders might be medical rather than moral conditions (or ‘kinds’). My concern is rather with the coherence of the position that, although those disorders might be medical conditions, the Cluster B Personality Disorders are not. Both types of disorders are arguably mental (medical, clinical), because sat-isfaction of their diagnostic criteria would likely

yield conditions simultaneously satisfying the DSM criteria for ‘mental disorder.’ For violations of social or moral norms, when chronic, are likely to lead to the very sorts of problems (distress, disability, death, loss of freedom) specified in the DSM criteria. Moreover, as with the Cluster B disorders, the Cluster A and C disorders are arguably “manifestation[s] of . . . dysfunction in the individual” (APA 2000, xxxi), dysfunction that is behavioral as well as psychological, that is, grounded in both actions and attitudes. And, as in the case of the Cluster B disorders, there is experimental evidence of underlying neurobiologi-cal dysfunction in the Cluster A and C disorders (Oldham 2005).

Thus, the very sorts of considerations that un-dermine Charland’s argument from identification would seem to undermine the preceding argument for the social (vs. mental) nature of the Cluster A and C Personality Disorders. Now it may turn out that chronic violations of moral norms are less likely to coincide with DSM ‘mental disorder’ than are chronic and violations of social norms that are not distinctively moral. However, that is not an argument that Charland makes. It is neverthe-less an argument he might consider making if he wishes to distinguish between the DSM Personality Disorders in the way that he does.

Let’s now move on to a second argument for the moral (vs. mental) nature of the Cluster B Personality Disorders: Charland’s ‘argument from treatment.’

The Argument From Treatment (Charland 2004, 2006)

According to this argument, it is impossible to imagine a successful treatment or cure for a Clus-ter B Personality Disorder that does not involve a willed and effortful ‘conversion or change in moral character.’ Therefore, the Cluster B Personality Disorders are moral rather than mental (medical, clinical) disorders.

This argument captures the intuition, argu-ably a truism, that an undesirable condition is a moral condition if its amelioration or elimination requires a change, a willed and effortful change,


in moral character. As with Charland’s argument from identification, the argument here can be critiqued directly as well as indirectly. Let’s begin with a direct critique.

Direct CritiqueThe problem with Charland’s argument is not

so much with the strength of its inference (but see Pickard 2009) as with the credibility of its single premise. What is ‘impossible to imagine’ is a successful treatment (or cure) that does not involve the reduction or elimination of the morally disvalued traits that lead to a Cluster B diagnosis in the first place. Such a treatment is not simply ‘impossible to imagine,’ it is logically impossible, as Charland himself emphasizes. For the Cluster B disorders are defined by morally disvalued traits. However, there is no obvious need to conceptual-ize effective treatment in terms of “some sort of conversion . . . in moral character,” in terms of “moral willingness, moral change, and moral ef-fort” (Charland 2006, 123). We might accordingly revise the premise of the argument from treatment so that it reads:

It is impossible to imagine a successful treatment or cure for a Cluster B Personality Disorder that does not involve the reduction or elimination of the morally disvalued traits that give rise to a Cluster B diagnosis.

However, when so revised, the premise would seem to provide little support for the desired conclusion, namely, that the disorders in question are moral rather than mental disorders. For the specified reduction/elimination could be achieved, at least in principle, via standard forms of psychiatric treatment, whether pharmacological or psycho-therapeutic. As Charland himself concedes (2004, 69) such treatability would constitute confirma-tion, however weak, of presumptive medical/clinical status.

Charland, however, denies that pharmacologi-cal and/or psychotherapeutic treatment could ever eradicate a Cluster B (vs. A or C) disorder. Such therapy would be the wrong kind of treatment for character disorders, just as (Charland might claim) moral therapy would be the wrong kind of treatment for medical disorders. For Charland, there is a “moral line in the sand” that standard psychiatric treatments (particularly pharmacologi-

cal ones) “cannot cross” (Charland 2006, 123). Successful treatment would require, according to Charland, a special kind of “moral commitment” (p. 122) on the part of the Cluster B patient. It would require that the patient commit to making changes that are distinctively moral. These are the sorts of changes that might be summed up in terms of the vague, morally laden, notions of ‘becoming a more virtuous person’ or ‘improving one’s moral character.’ In essence, any treatment that does not specifically target moral character is (according to Charland) bound to fail, or at least fall short of a complete cure.

Charland sees confirmation of this idea in the well-documented success of “Dialectical Behavior Therapy,” often used in treating patients with Borderline Personality Disorder (Charland 2006, 123–4). The underlying moral nature of this popu-lar therapy is, according to Charland, “adroitly concealed beneath its clinical description” (Char-land 2006, 123). That a putatively moral therapy seems to ‘work for’ one of the Cluster B disorders lends credence (according to Charland) to the idea those disorders are indeed moral disorders.

Whether Charland is right in construing Dia-lectical Behavior Therapy as an essentially moral therapy is a difficult question, one that I will not address here. However, quite apart from Char-land’s controversial interpretation of Dialectical Behavior Therapy, there are a couple of reasons to question his view that effective treatment of a Cluster B disorder would require a distinctively moral commitment on the part of the patient. First, effective pharmacological treatment would presumably obviate the need for any such com-mitment. And, as just noted, such treatment is possible, at least in principle. Indeed, two of the four Cluster B disorders, Antisocial and Border-line, have already proven responsive to treatment with fluoxetine, which tends to reduce aggression in the former (Coccaro and Kavoussi 1997) and anger in the latter (Salzman et al. 1995). And although recent studies indicate that Borderline Personality Disorder is especially responsive to pharmacotherapy (Zanarini 2004), there is grow-ing evidence of responsiveness with respect to the Cluster B disorders more generally. Divalproex, in particular, has been shown to curb the impulsive


aggression that characterizes those disorders as a whole (Hollander et al. 2003). It is likely that increasingly effective pharmacological treatments are in the offing, given the extensive research cur-rently being done on the brains of those whose attitudes and actions are chronically antisocial (Raine 2008).

Thus, it is far from obvious that successful treat-ment of a Cluster B Personality Disorder would necessitate any sort of ‘special’ commitment on the part of the patient, any commitment beyond the standard commitment to treatment adherence. Were the envisioned treatment pharmacological, the situation would arguably parallel that of the Cluster C patient taking benzodiazepines for her anxiety. Just as the Cluster C patient taking diaz-epam does not have to ‘commit to’ becoming less anxious in ordinary social situations, the Cluster B patient taking fluoxetine (or some empathy-enhancing drug of the future) does not have to ‘commit to’ becoming less aggressive with friends, family, or co-workers. In both cases, the prescribed medications would be expected to ‘do the work,’ at least so long as the patient adhered to treat-ment guidelines. One might counter that while such medications might treat the symptoms of a Cluster B disorder, they would invariably fail to address the underlying cause of those symptoms, arguably a moral condition. They would accord-ingly fall short of a genuine ‘cure.’ In response, I would ask whether there are any sound reasons are for supposing that the ‘underlying causes’ of Cluster B disorders are not neurobiological (vs. moral) ones.

Second, even if the envisioned treatment were psychotherapeutic (Verheul and Herbrink 2007), there is no obvious reason to suppose that the patient would have to commit to making changes conceptualized in the idioms of ‘moral character’ and ‘moral conversion.’ For although successful treatment would, of course, require adherence to treatment guidelines, the goal of such adherence need not (although it might) be conceptualized in moral terms, in terms of (for example) ‘becoming a more virtuous person’ or ‘improving one’s moral character.’ Depending on the particular form of psychotherapy adopted, general treatment goals might be conceptualized in terms of (for example)

‘recovery from illness,’ ‘getting better,’ ‘becoming healthier,’ ‘becoming whole,’ or ‘improving one’s quality of life.’ Similarly, patients suffering from schizophrenia need not conceptualize therapeutic goals in medical terms (e.g., ‘controlling the symp-toms of mental illness’) and arguably should not if a non-medicalized conception is what works best for them (Reimer 2010b, 2010c). Ideally, the Cluster B patient adheres to psychotherapeu-tic treatment regardless of whether she (or her therapist) conceptualizes the prescribed treatment in terms of some sort of ‘conversion or change in moral character.’ Ideally, the result of such adher-ence is reduction or elimination of the morally disvalued traits that led to the patient’s diagnosis in the first place.

Indirect CritiqueLet’s now turn briefly to an indirect critique of

Charland’s argument from treatment. The critique can be conducted by constructing and critiquing a parallel argument for the social (vs. mental) nature of the Cluster A and C Personality Disorders, dis-orders that, according to Charland, may well be genuine mental (medical, clinical) disorders. The argument goes as follows:

It is impossible to imagine a successful treatment or cure for a Cluster A or C Personality Disorder that does not involve a willed and effortful ‘conversion or change in social character.’ Therefore, the Cluster A and C Personality Disorders are social rather than mental (medical, clinical) disorders.

Here, the weakness of the argument parallels the weakness of Charland’s argument from treatment. First, there is no need to conceptualize successful treatment or cure in terms of ‘some sort of con-version or change in social character.’ One need only conceptualize it in terms of the reduction or elimination of the socially disvalued traits that led to a diagnosis with a Cluster A or C disorder in the first place. Second, so conceptualized, there is no difficulty in the idea that ‘a successful treatment or cure’ might be effected in either of the usual ways: pharmacologically or psychotherapeutically. This would of course be consistent with the idea that those disorders are genuine mental disorders.

All in all, Charland’s arguments from identi-fication and treatment, their initial plausibility


notwithstanding, do not seem to lend much cre-dence to the idea that the Cluster B Personality Disorders are moral rather than mental (medical, clinical) disorders. Nevertheless, there does seem to be an intuitive difference between the Cluster B disorders and paradigm medical disorders. This difference is nicely captured in an argument of Carl Elliott’s, to which I now turn.

The Argument From Illness (Elliott 1996)

In discussing the issue of moral responsibility in connection with the DSM Personality Disor-ders, Elliott (1996) assumes those disorders to be genuine mental disorders. His primary concern is with the idea that their status as such might be taken to diminish moral responsibility. However, Elliott also expresses concerns with regard to the presumptive ‘illness status’ of the DSM Personality Disorders. For what is generally true of illnesses is not (according to Elliott) generally true of those disorders—not when consideration is given to issues of treatment, etiology, unwantedness, and diagnosis (Elliott 1996, 62).

Instead of looking at this particular argument, I would like to consider a restricted version of it, one that applies specifically to the Cluster B Per-sonality Disorders. This restricted version of the argument, to which Charland (2006, 121) seems sympathetic, might be called the “argument from illness.” In essence, it goes like this:

What is generally true of illnesses is not true of the Cluster B Personality Disorders. Therefore, it is unlikely that the Cluster B Personality Disorders are illnesses.

The argument from illness captures the folk intu-ition that the Cluster B Personality Disorders are so unlike the vast majority of illnesses that they are unlikely to be ‘real’ illnesses. That one does not have to be a ‘real’ doctor, a medical doctor, to diagnose and treat Cluster B disorders, might seem to lend credence to this intuition.

However, as with the arguments from identifi-cation and treatment, the argument from illness is not quite as strong, logically speaking, as the intuition it captures. The strength of the argument might be questioned on two grounds. First, the premise is not as transparently true as it might initially seem to be. Second, the inference from

premise to conclusion is weaker than one might at first suspect. Let’s consider these two points in turn, beginning with the first.

A Questionable PremiseConsider the sort of evidence Elliott might of-

fer on behalf of the argument’s single premise. It would likely be the very same evidence he offers on behalf of the more general premise of the original argument: that what is generally true of illnesses is not generally true of the DSM Personality Dis-orders. In particular, illnesses are generally (i) diagnosed for the purpose of treatment (ii) thought to involve some sort of “underlying organic, physi-ological abnormality” (iii) unwanted and (iv) not diagnosed solely on the basis of behavioral signs (Elliott 1996, 62). In contrast, none of (i)–(iv) characterizes the DSM Personality Disorders, including those in Cluster B.

Let’s consider, individually, the issues of: ra-tionale for diagnosis, etiology, unwantedness, and diagnostic criteria. Regarding rationale for diagnosis: Cluster B Personality Disorders are sometimes (if infrequently) diagnosed for the pur-pose of treatment. This is true of both Histrionic and Narcissistic Personality Disorder (Callaghan et al. 2003), and is especially true of Borderline Personality Disorder (Fonagy and Bateman 2006). In the case of the latter disorder, diagnosis for the purpose of treatment is arguably motivated by two considerations. First, Borderline patients often seek treatment for their condition on account of the considerable distress it causes them. Second (and relatedly), effective treatments, psychothera-peutic as well as psychotropic, are in fact available (Fonagy and Bateman 2006). However, neither failure to seek treatment for a particular condition, nor unavailability of effective treatment for that condition, provide much in the way of evidence for the idea that the condition in question is not an illness. Patients suffering from hypertension, adult-onset diabetes, and arteriosclerosis often fail to seek treatment for those conditions. For they are characteristically unaware that there is anything ‘wrong with’ them. Moreover, the fact that effective pharmacological treatments were not available until fairly recently certainly does not suggest that those conditions were not illnesses


before such treatments became available. They were causing disability and premature death long before they were even recognized as illnesses, let alone treatable illnesses.

Regarding etiology: As noted, two of the four Cluster B Personality Disorders—Antisocial and Borderline—seem to involve underlying neuro-logical dysfunction. One might reasonably counter that ‘dysfunction’ is not quite the same as ‘organic abnormality.’7 However, although ‘organic abnor-mality’ is not thought to underlie migraines, neu-rologists do not argue on that basis that migraines might not be genuine medical disorders. Thus, absence of ‘underlying organic, physiological ab-normality’ in Antisocial and Borderline patients should not lead us to conclude, without further argument, that those disorders are not genuine mental (vs. moral) disorders. Presence of neuro-logical dysfunction, on the other hand, arguably should lead us to conclude that those disorders might be genuine mental (vs. moral) disorders.

But what of the other Cluster B disorders—Histrionic and Narcissistic? Although there is currently little if any (direct) experimental data to support the idea that these disorders are associ-ated with neurological dysfunction, the relevant studies have yet to be conducted. Moreover, given the overlap in diagnostic criteria with Antisocial and Borderline Personality Disorder, it is not un-reasonable to suppose that these other disorders might involve similar neurological dysfunction. Apparent responsiveness to certain forms of psychopharmacology (as noted) provides further support for this supposition.

Regarding unwantedness: Although those with Cluster B Personality Disorders might not always, or even generally, see their disorders as ‘unwanted,’ perhaps that is only because they do not see those conditions as causing them harm. Indeed, they might not even see themselves as having any sort of ‘condition’ to begin with, let alone an undesirable one amenable to psychiatric treatment. Similarly, patients suffering from condi-tions like hypertension, adult-onset diabetes, and arteriosclerosis might not see those conditions as ‘unwanted.’ They might not believe that there is anything medically wrong with them because they do not feel as though there is. They do not feel

‘ill.’ That their primary care physician is able to back her claims with diagnostic test results might not be enough to sway their conviction that they are perfectly healthy.

Finally, regarding diagnostic criteria: Although the Cluster B Personality Disorders are diagnosed largely (although not entirely) on the basis of be-havioral signs, the same is true of other disorders whose illness status is less controversial. Indeed, as Elliott himself concedes (1996, 129), “diagno-ses of some organic disorders are usually made solely on the basis of behavior, such as Alzheimer’s disease.” The same is surely true of some non-organic disorders, including Autistic Disorder, the essential features of which are “the presence of markedly abnormal or impaired development in social interaction and communication and a mark-edly restricted repertoire of activity and interests” (APA 2000, 70).

Thus, the premise of the argument from illness is not as transparently true as it might initially seem to be. For Cluster B disorders are sometimes diagnosed for the purpose of treatment and there is mounting evidence of underlying neurological dysfunction, dysfunction amenable (at least in principle) to pharmacological treatment. More-over, although those disorders might not gener-ally be ‘unwanted,’ and although their diagnostic criteria are largely behavioral, the same might be said of various conditions whose illness status is uncontroversial. But even if one were to grant the premise of the argument from illness, the inference from premise to conclusion is rather weak. Let’s now turn to that inference.

A Questionable InferenceTo appreciate the inference’s weakness, consider

a parallel inference involving fibromyalgia. What is generally true of illnesses is not true of fibro-myalgia. Therefore, it is unlikely that fibromyalgia is an illness.

To assess this inference, one needs to know something about fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread pain, stiffness, and tenderness in the muscles, tendons, and joints. Its symptoms are diverse and include fatigue as well as disturbances in sleep, cognition, and mood. It is more common


in women than in men and its etiology unknown. It is diagnosed on the basis of clinical findings, although diagnostic tests are typically used to rule out other conditions. Treatment programs are diverse, reflecting the diversity of the condition’s symptoms (Isenberg et al. 2004).

Let’s now turn to an assessment of the inference. The inference seems to be weak, but what is the source of its weakness? Perhaps fibromyalgia fits most naturally into a recognized class of illnesses that are not, in certain notable respects, typical illnesses. The relevant differences might have to do with (inter alia) diversity of symptoms and/or comparative ignorance or presumed complexity of etiology. In that case, the comparison class, illnesses generally, might be too broad given the desired conclusion: that fibromyalgia is not an ill-ness. The comparison class should arguably be the particular class of illnesses to which fibromyalgia is most likely to belong, not illnesses generally.

Fibromyalgia is generally regarded as a rheu-matic illness: a disorder involving the joints or connective tissue. The rationale for such a view is straightforward. Fibromyalgia has much in common with paradigm rheumatic disorders, in-cluding lupus and rheumatoid arthritis (Isenberg et. al 2004). Most obviously, all three conditions are characterized by chronic and widespread joint pain. Remaining symptoms are notable for their diversity. As with patients diagnosed with lupus and rheumatoid arthritis, those diagnosed with fibromyalgia frequently report fatigue and sleep disturbances. Disturbances in mood and cognition are also frequently reported by patients suffering from each of these three disorders. Additionally, all three conditions are more common in women than in men and all three have etiologies that are poorly understood. Finally, in all three cases, di-versity of treatment programs reflects the diversity of the condition’s symptoms.

Comparison of fibromyalgia with rheumatic illnesses would seem to yield a stronger inference than comparison of that condition with illnesses more generally. To see this, just consider the fol-lowing inference:

What is generally true of rheumatic illnesses is not true of fibromyalgia. Therefore, it is unlikely that fibromy-algia is a rheumatic illness.

Intuitively, this inference is considerably stronger than that comparing fibromyalgia with illnesses generally. One could then get from its conclusion to the desired conclusion, that it is unlikely that fi-bromyalgia is an illness, via the (not unreasonable) assumption that if fibromyalgia is an illness, then it is likely to be a rheumatic illness. However, the comparative strength of the inference comes at the expense of a considerably less plausible premise. For fibromyalgia (as just noted) has much in com-mon with rheumatic illnesses, which is why those who believe in the illness status of fibromyalgia generally regard it as a rheumatic illness. (This is not to deny notable differences. Fibromyalgia, in contrast with paradigm rheumatic illnesses, is currently diagnosed solely on the basis of clinical findings; diagnostic tests are used only to rule out other conditions.8)

Similar considerations apply to the argument from illness. The comparison class should arguably be psychiatric and/or neurological illnesses, rather than illnesses generally. Thus, a more appropriate argument, given the desired conclusion, would be:

What is generally true of psychiatric/neurological ill-nesses is not true of the Cluster B Personality Disorders. Therefore, it is unlikely that those disorders are psychi-atric/neurological illnesses.

One could then argue from the conclusion of the foregoing to the desired conclusion, that it is unlikely that the Cluster B Personality Disorders are illnesses, via the plausible assumption that if they are illnesses, they are likely to be psychiatric/neurological illnesses.

Although the inference of the revised version of the argument from illness is not as weak as that of the original argument, the credibility of its premise is correspondingly diminished, thereby weakening the case for the desired conclusion: that it is unlikely that the Cluster B disorders are illnesses. For what is generally (or at least often) true of psychiatric/neurological illnesses arguably is true of the Cluster B Personality Disorders. Psychiatric/neurological illnesses are often difficult to treat; their etiologies (frequently expressed in the language of ‘dysfunction’) are often poorly understood. Such is the nature of illnesses based in the brain, an immensely complex and incom-pletely understood organ. In cases where effective


treatments are not (yet) available, diagnoses might nevertheless be made if only to give a name to what is causing the patient’s otherwise mysteri-ous and often disturbing symptoms. In the case of the Cluster B Personality Disorders, it might be frustrated friends or family members, rather than the patient himself, who feels a sense of reassur-ance when the disorder is given a name. For the patient might regard his so-called symptoms as neither mysterious nor disturbing—yet the same might be said of patients suffering from less con-tested (neuro)psychiatric disorders, such Autistic Disorder or Alzheimer’s disease.

Relatedly, those suffering from psychiatric/neurological disorders do not always view their ‘condition’ as unwanted. This might be because they do not recognize themselves as having an undesirable condition amenable to psychiatric or medical treatment. They lack ‘insight.’ This is paradigmatically true of patients suffering from Anorexia Nervosa and Manic/Hypomanic Episodes (APA 2000, 357–68). Finally, there are recognized neuropsychiatric disorders that are diagnosed largely, if not entirely, on the basis of behavioral signs. Autistic Disorder (as noted) is a case in point. Tourette’s Disorder might provide a further example, because its characteristic tics are arguably behavioral signs, falling somewhere between the ‘fuzzy’ constructs of ‘voluntary’ and ‘involuntary’ (Stein et al. 2010). Some might even include Attention-Deficit Hyperactivity Disorder, although the case can be made without appeal to this controversial diagnosis.

In sum, the inference drawn in the revised ver-sion of the argument from illness is a fairly strong one. However, its single premise is not especially plausible, not when the points of comparison are the four points invoked by Elliott: rationale for diagnosis, etiology, unwantedness, and diagnostic criteria. For with respect to these particular points, the Cluster B Personality Disorders seem quite similar to a variety of paradigm psychiatric and neurological disorders. Indeed, such similarities might be invoked support a ‘Roschian’ construal of the Cluster B disorders as mental disorders (Kendell 2002, 113).

Implications, Practical and Theoretical

In concluding, I would like to point out a couple of implications, practical as well as theoretical, of a ‘fundamentally mental, contingently moral’ in-terpretation of the Cluster B Personality Disorders.

The most obvious practical implication is that the Cluster B Personality Disorders should not be omitted from future editions of the DSM on the grounds that they are moral rather than mental disorders. This is not, of course, to deny that there might be other (and better) reasons for removing those disorders from the DSM—or perhaps more realistically, for revising how they, and the Person-ality Disorders more generally, are conceptualized therein (Skodol and Bender 2009). As far as the theoretical implications go, the most important of these has to do with the nature of mental disorder. Mental disorders can, and sometimes do, manifest themselves through morally disvalued traits—at least when ‘mental disorder’ is conceptualized as in the (current) DSM. It is, of course, possible that the operative concept of ‘mental disorder’ might change in ways that would effectively preclude those currently diagnosed with (only) Cluster B disorders from being diagnosed with any sort of mental disorder. But that would be as problematic as it is unlikely (Stein et al. 2010). For Cluster B patients seem to have much in common with those suffering from paradigm psychiatric (and even neurological) disorders. Adding a proviso to the effect that no ‘mental disorder’ can be diagnosed primarily on the basis of morally disvalued traits would be patently ad hoc given such commonali-ties.

How, then, is one to respond to the inevitable charge of ‘medicalizing morals’? One might, and arguably should, plead guilty to such a charge—given a neutral (vs. pejorative) reading of ‘medi-calization.’ For it would seem that ‘medicalization of morals’ is indeed sometimes appropriate. It is appropriate in cases where ‘moral disorder’ is presumed to stem from mental (and ultimately neurological) disorder.


AcknowledgmentsThe author thanks two anonymous reviewers

for comments that were as extensive as they were helpful. I would also like to thank the students in my 2009 Proseminar in Analytic Philosophy of Psychiatry for their many helpful comments on issues relating to the topic of the present paper. Comments from Eyal Tal and Will Leonard were especially helpful. Thanks also go to Rachana Ka-mtekar, Nolan Majors, Connie Rosati, and Mark Timmons. Finally, special thanks go to Richard J. Reimer for his knowledgeable comments regarding neurological matters.

Notes1. Another view would be that the Cluster B dis-

orders are moral disorders that are a kind of (DSM) mental disorder. They are disorders involving an im-paired relation to moral reality, where such impairment can be captured only in moral language. (Thanks to Connie Rosati for this point.) Such a view seems to be consistent with the view defended herein. However, its formulation conflicts with Charland’s notion of ‘moral disorder’ (adopted here), on which effective treatment of such disorders requires non-medical intervention.

2. Charland does acknowledge that standard forms of clinical therapy might be of use in treating those with Cluster B disorders. However, he believes that any fully successful treatment or cure will require some form of distinctively “moral” therapy.

3. Because Charland (2010) acknowledges the pos-sibility that the Cluster B disorders might one day be reformulated in a manner that leads to reliable iden-tification using only non-moral terms and concepts, considerations of charity demand that the argument’s conclusion be couched in terms of “presumptive” moral status.

4. One might suppose that morally neutral diagnos-tic criteria could, in theory, replace the current mor-ally laden criteria, thereby undermining the putatively moral status of the Custer B disorders. However, such a supposition is problematic for a number of reasons (Reimer 2010a).

5. British psychiatrists might not agree with their American counterparts, including with respect to the putative mental disorder status of personality disorders. (See Kendell 2002 for a critique of this attitude.)

6. These three levels of dysfunction are importantly related, given the dependence of behavior, cognition, and affect on brain processes (Stein et al. 2010). How to conceptualize ‘dysfunction’ in a way that unites these levels is a difficult issue that does not seem to be ap-

proaching any sort of consensus (First and Wakefield 2010; Stein et al. 2010; Verhoeff and Glas 2010).

7. As one neurologist explained to me, the concept of ‘organic brain disorder’ is likely to fall out of favor. It used to be used to distinguish between disorders with established identifiable structural abnormalities (e.g., plaques and tangles and the loss of neurons in Alzheimer’s disease) and disorders without such findings (e.g., migraines, depression, schizophrenia). Because neuroscientists have found molecular pathology to be associated with various disorders once considered non-organic (e.g., familial migraine for which specific genetic defects are now known), the ‘organic brain disorder’ classification may well become obsolete.

8. This difference is of particular relevance to the “Fi-bromyalgia Wars” (Wolfe 2009) currently being waged over the condition’s status as a ‘real disease.’ However, the debate here does not quite parallel that over the illness status of the Cluster B disorders. For some who deny the disease status of fibromyalgia see that condi-tion as a genuine mental disorder; others view it as a medically treatable ‘pain syndrome.’ No one seems to view it as any sort of moral condition.

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