How to Cut the Psychiatric Pie: The Dilemma of Character

Introduction

In brief, Matthews contends that there are different types of psychiatric disorders, some of which concern not medical illness or disease but character, or ways of being.The latter, Matthews argues, are appropriately approached by psychotherapy, which can be seen as a type of moral education. Finally, he asserts that Aristotle’s discussion of moral development can help us to understand these latter types of problems, while neither Mill nor Kant provide a conceptual framework within which such problems can be understood.

The Issue of Taxonomies

That there are diverse types of disorders that fall under psychiatry’s purview challenges both our taxonomy and our conception of the nature of psychiatric expertise. To clarify the distinctions among types of problems that psychiatrists treat, I prefer the general term disorder to illness or disease, which already connote a particular subtype of disorder characterized by specific attributes. The issue of how to subdivide this diverse field continues to intrigue us. How to cut the pie? One taxonomy (McHugh and Slavney) differentiates the perspectives of disease, dimension, behavior, and life story. Disease implies a clinical syndrome linked to organic pathologic mechanisms and etiologic agents. Dimensions, such as intelligence in the cognitive realm, or reactivity and extraversion/introversion in the realm of affect, are common to all of us. They are predispositions that generate emotional responses to certain circumstances. Disease and dimension might seem most pertinent to Matthew’s discussion, but behavior and life experiences are also germane.

Another (and to my mind less useful) way of dividing the pie is between the biological and psychological domains. The problem is that as we come to understand better the nature of brain processes, it is not clear where one stops and the other begins. Asking which is mind and which is brain may be the wrong question to ask when both operate in parallel. Thus, using McHugh and Slavney’s taxonomy, demonstrable biological processes clearly predominate in the disease perspective. However, biological issues surface in the propensity to react strongly or not at all to affective stimuli (dimension); in the biological predisposition to drink to excess, to engage in high-risk activities, or to take impulsive violent action against self or others (behavior), which may relate to low seritonergic tone (Asberg; Brown; Van Praag; Virkkunen); and even in life histories, when repeated early stress sets up a high arousal state in brain endocrinology (Lucey 1997). Biology is everywhere. But so is psychology. Chronic illnesses such as asthma, diabetes, and hypertension may worsen in the presence of significant psychosocial stress.

A third approach, “nature versus nurture,” unnecessarily models an opposition rather than a synergism between two developmental influences. An infant’s biological/genetic predisposition or style evokes particular types of nurturing responses in caregivers, while inhibiting other responses (Stern). We know that the development of speech depends on stimulation of the auditory system at a critical period in development, and that aspects of vision depend on visual stimulation at analogous critical periods.

Twenty years ago, psychiatrists knew what character was and was not, and that character came from upbringing. Now, fortunately, we are more confused. How does Matthews help us? His idea of moral disorders appeals to our common sense—not everything is a disease, and some psychiatric problems present different issues than do many medical problems. To my mind, however, his arguments present a number of difficulties, and his clinical examples do not help his case. Although he aspires not to cut the pie into biological versus psychological parts, in fact he does so and he founders.

Problems Raised by Clinical Examples

1. Obsessive-Compulsive Disorder versus Obsessive-Compulsive Personality Disorder

Matthews confounds obsessive-compulsive disorder (OCD) with obsessive-compulsive personality disorder. The former, a clinical syndrome whose pathologic mechanisms are beginning to be elucidated (Aylward; Azari; Cottraux; Lucey 1995; Rauch), has been highly resistant to psychodynamic psychotherapy, though impressively approachable with psychopharmacologic and behavioral methods. At least one small study suggests changes occur in brain metabolism after behavioral therapy (Schwartz); other studies have shown such changes with pharmacological treatment (Perani; Rubin). It would twist the meaning of...