Mental Illness Vs. “Bad” Behavior

Philip Hickey, PhD
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On February 14, 2017, the very eminent psychiatrist Allen Frances, MD, published a letter in the New York Times.  The main points of Dr. Frances’s letter are:

  1. That, contrary to some speculations and assertions, Donald Trump, President of the USA, does not meet the criteria for narcissistic personality disorder “because he does not suffer from the distress and impairment required to diagnose mental disorder.”
  2. That “bad behavior is rarely a sign of mental illness…”

Seven months later (September 2017), Dr. Frances gave an interview to Mary Elizabeth Williams. The interview was published on ALTERNET, and it restated and reinforced the points made in the letter to the New York Times. Here’s a quote from the interview:

“It’s a great mistake to confuse bad behavior with mental illness.”

Clarification: This post is not about Donald Trump. Rather, it is about the invalidity of the concept of mental illness.

CONDUCT DISORDER

Let’s start with the quote from the ALTERNET interview:

“It’s a great mistake to confuse bad behavior with mental illness.”

Obviously, the word “bad” in this kind of context is value-laden, and as such defies formal definition. But for the sake of discussion, let’s set that issue aside, and let’s think of “bad behavior” as “behavior that attracts widespread disapproval,” or “behavior that harms others,” etc.

Essentially Dr. Frances is drawing a sharp line between mental illness and “bad behavior.” But, in reality, “bad behavior” is formally classified as a “mental illness,” and has been listed as such in successive editions of psychiatry’s Diagnostic and Statistical Manual (DSM).

In fact, two separate psychiatric “diagnoses” consist entirely of “bad behavior.” These are conduct disorder and antisocial personality disorder.

Here are the criteria for conduct disorder as set out in Dr. Frances’s very own DSM-IV (1994):

“A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:  

Aggression to people and animals 

(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity  

Destruction of property 

(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others’ property (other than by fire setting) 

Deceitfulness or theft 

(10) has broken into someone else’s house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., ‘cons’ others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

 Serious violations of rules 

(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B.  The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C.  If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.” (p 90-91)

The criteria are essentially similar in DSM-5 (2013).

So, conduct disorder, a “bona fide” psychiatric illness, listed and described in the DSM, consists essentially of “bad behavior,” by any conventional standards. DSM-IV elaborates considerably on the criteria items, for instance:

“Physical violence may take the form of rape, assault, or, in rare cases, homicide.” (p 86)

All of which would, I suggest, be considered “bad” by most people.

. . . . . . . . . . . . . . . .

Here are the DSM-IV criteria for antisocial personality disorder:

“A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder…with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.” (p 649-650)

As with conduct disorder, DSM-IV elaborates considerably on these criteria, e.g.:

“…destroying property, harassing others, stealing, or pursuing illegal occupations.” (p 646)

“…commit acts or physical assault (including spouse beating or child beating) (p 646)

In addition to conduct disorder and antisocial personality disorder, there are many other “diagnoses” in DSM-IV in which criminal activity is an integral part of the presentation.

These include:

pyromania (deliberate fire-setting)
intermittent explosive disorder (serious assaultive acts or destruction of property)
kleptomania (habitual stealing)
pedophilia (sexual activity with a pre-pubescent child)
sexual sadism (may entail “rape, cutting, stabbing, strangulation, torture, mutilation, or killing”)

So it is clear that two of the so-called mental illnesses (conduct disorder and antisocial personality disorder) consist essentially of “bad” behavior, while in at least six others, “bad” behavior is an integral part of the problem.

Nevertheless, Dr. Frances assures us that: “It’s a great mistake to confuse bad behavior with mental illness.” And in the letter to the NYT: “Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely.” Yet the DSM-IV section on conduct disorder states clearly:  “…for males under age 18 years, rates range from 6% to 16%; for females, rates range from 2% to 9%.” (p 88) And: “the overall prevalence of Antisocial Personality Disorder in community samples is about 3% of males and about 1% of females.” (p 648)

So these can hardly be described as rare “mental illnesses.” In fact, DSM-IV also states that conduct disorder “is one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children” (p 88) and that prevalence estimates for antisocial personality disorder within clinical settings “have varied from 3% to 30% depending on the predominant characteristics of the populations being sampled.” (p 648) Again, this is clearly not a rare problem.

The fact is that since DSM-III, every significant problem of thinking, feeling, and/or behaving (including criminal activity) is considered by psychiatry to be a “mental illness.” This spurious notion has been re-stated and promoted in all subsequent editions, including DSM-IV and DSM-IV-TR, of which Dr. Frances was the architect.

Within the fraudulent psychiatric framework, criminal activity is not only a “mental illness” in its own right, it is also a primary gateway to the psychiatric system, where a wide range of “treatable” concurrent disorders are “uncovered.”

“Individuals with Conduct Disorder are at risk for later Mood or Anxiety Disorders, Somatoform Disorders, and Substance-Related Disorders.” (DSM-IV, p 89)

“Individuals with this disorder [antisocial personality disorder] may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood.  They may have associated Anxiety Disorders, Depressive Disorders, Substance-Related Disorders, Somatization Disorder, Pathological Gambling and other disorders of impulse control.” (p 647)

Court-mandated psychiatric “treatment” is common throughout the USA, and within the prison community it is well-recognized that availing of psychiatric “care” and taking the pills as prescribed increases one’s chances of parole. Continuing with “treatment” after discharge is often a condition of early release.

In this context, it is, I suggest, deceptive of Dr. Frances to assert that one can and should draw a sharp line between “bad behavior” and “mental illness.” Within the psychiatric drug-pushing business, crime is a mental illness, and is routinely used by psychiatrists as justification for enrolling individuals into the psychiatric system, in which they often remain enmeshed for years, decades, and even for life.

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52 COMMENTS

  1. Great article, Phil. When manic, my own bad behaviour has sometimes been written off as mental illness. Clearly, it’s not illness because, if it was, I wouldn’t be divorced and have a criminal record. It was bad behaviour with painful consequences. The answer is to make better choices in the future.

  2. Has anybody seen the title of Allen Frances new book? It’s called Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump. I haven’t got the words to describe the audacity of a person who would diagnose the American people while sparing their elective pompous ass. Maybe you have some.

    The nation (i.e its people) are “distressed” and “impaired”, but Donald “the Tweet” Trump isn’t. Excuse me, but I must have missed a great deal of the calm and lucidity demonstrated by our current head of state in recent weeks. You see how shaky this matter can become when it all boils down to “expert opinion”, as fallible as some “experts” prove to be.

    Another terrific post, Dr. Hickey. As always, it is engaging to read your analysis and critique. Keep them coming.

    • President Trump and those like him don’t need “mental illness” diagnoses when words like”hothead” work just as well. A decent social media consultant would make him write down his tweets ahead of time and wait at least an hour before posting.

      And as I said on another article written by you, Dr. Hickey, Dr. Frances and the other high-ranking psychiatrists really can’t keep their stories straight.

      Stigma makes a useful tool when they can use it to practice coercive “treatments.” But it’s a knife without a handle. Understandably few people relish the idea of having their reputations ruined as hopelessly “severely mentally ill.” This makes them reluctant to get the help they so sorely need. And by “they” I mean the psychiatrists of course, since they need consumers for their 6 or 7 digit incomes. Those they already keep have a bad habit of dying young. Alas.

      • People here keep talking about mental health workers “lining their pockets”, “money” etc.

        Here, in my country, there are many hospitals, some run by the state, some run by religious organisations (like Christian missionaries) where the doctors don’t get paid anything close to what they could make in private practice or by going to the west. I think many of them are completely aware of the “money” card that will be thrown at them and choose to have no conflicts of interests of that sort.

        But guess what. The same stuff still happens. Psychiatry is still psychiatry.

        They still label people with junk. They still tell families that if their children become manic from psychiatric drugs, that they have “bipolar disorder”. They still result in the psychiatric indoctrination of families. Their methods still cause the social and legal issues and misuse of psychiatry that is consistently prevalent around the world, wherever psychiatry exists. It still results in the unintentional (on the part of psychiatrists) abuse of already abused people.

        The worst part is, hell, they don’t even NEED to label people here. In western countries, people get labelled, because insurance needs it for billing. Most people here pay cash (because it’s nowhere near as expensive as in the west), and yet, they STILL use DSM labels. They are STILL used in courts of law to defame people, to obfuscate truths, to write lies or manipulations, in order to win cases.

        So, I don’t think money, and “them lining their pockets” is the only issue here. You could turn that “money” card on antipsychiatry people as well, claiming they do their work to sell books etc.

        • Actually political spendthrifts out to cut social programs have utilized antipsychiatry arguments to serve their own purposes, and then you’ve got shrinks blaming antipsychiatry for this spendthrift position. Witness the current counter revolution–the expanded community mental health containment system (many mini-institutions) and forced outpatient drugging court orders. You can’t really outlaw books though, not so long there are book buyers, and freedom of choice and expression is valued.

  3. Really interesting article.

    So psychiatry is muscling in on the criminal justice system is it?

    This makes Frances assertion that a whole load of prisoners should be in psychiatric hands seem like him and his colleagues just touting for extra business and not being about caring for people at all.

    • They “care” about keeping “consumers” just like Tim Murphy did as he shed crocodile tears about the suffering mentally ill who were sure to go on murderous rampages without his help.

      Real philanthropists and humanitarians don’t demonize the objects of their compassion. Did you ever hear Theresa of Calcutta bad-mouthing the lepers she served?

    • Psychiatry provides a defense from criminal culpability. I would say misbehavior rather than “bad” behavior because such is a leap to judgment, and a matter of degree or extent. Narcissistic personality disorder, for instance, is a label that is often used to further demonize suspects and convicted criminals. This is the same label being used on Donald Trump. Trump is under investigation as is.

      Proper behavior is improper in some quarters, and there is a vast gap between misdemeanor pranksterism, outside of Russia with its hooliganism designation anyway, and felonious acts committed with vicious intent. Stupid laws exist as well, enforced or unenforced, but that is a whole category unto itself.

        • True enough. Psychiatrists have been empowered by law, and just as the law has empowered them, the law has dis-empowered their clientele. This is not what the law is supposed to do (i.e. enforce illegal law, or legalize criminal behavior). We’ve got the constitution on our side, however it may be many years before the legal profession sees it that way. Imprisonment, coercion, drugging, electrically induced epileptic fits amazingly viewed as therapeutic, etc. What they do is not good, and it needs to be exposed as such. “Mental health law” is a loophole in the law that needs closing. Close that loophole, and once again people assaulted by the mental health system are human beings rather than sub-humans. Doing so would make them full citizens again rather than second, third, or fourth, etc., class citizens. Mental health institute workers and staff would again be covered by the law, and prosecute-able under it. Through medicalization (deception by people in the medical profession in collusion with law and politics), marginalization and dis-empowerment are what the system is all about, and these are things that stand in sharp contrast to a democratic system of governance.

  4. Phil Hickey remains a shining beacon of reason and truth in the midst of a desert of myth and manipulation, cutting through the “Newspeak” as others endlessly “rethink” psychiatry in search of a “perfect reform” that will erase all the inherent contradictions.

  5. Am guessing, but doubt there is anything in the DSM on the psychotic financial destruction derivative inventions of banksters, we have had (still have) CDS, HFT, CDO’s, let alone FRB. Watch out for the next phase of massive fraud via the block-chain. Blythe Masters is heavily into it, she who brought us: the CDS.

    Voltaire: ‘Wenn Du wissen&bloßstellen willst, wer dich beherrscht, musst Du nur herausfinden, wen Du nicht hinterfragen&kritisieren darfst.’

    ‘if you want to know who rules a society ask yourself this question: Who is it that I am not permitted to question & criticize?’

  6. The APA has tried to invent a “diagnosis” for everything. Several of those diagnostic codes are not real “illnesses” they are simply bad behavior given a diagnostic label. Many of the codes do not involve “behavior.” Like “math disorder.” There really isn’t any “behavior” involved in being bad at math. Let’s assume for a moment that 3 of 374 dsm5 codes include “bad behavior” but 371 do not. The current gun debate illustrates the problem with using “mental illness” as a criteria to deprive “the wrong people” of their second amendment rights. “The wrong people” are, presumably the ones who “behave badly”. The 3 “bad behavior” categories of 374. The problem is, if it comes down to creating legislation to restrict gun ownership to those who fall into these 3 categories, the people who fall into the other categories are swept up in the category of “bad behavior” because they are identified with a code. If “mental illness” was legislated to be a restrictor of gun ownership, anyone with a diagnostic code would be stripped of their rights under the second amendment. There would then need to be a “registry” (blacklist) of diagnostic codes that is available to “law enforcement” and gun shops. Imagine being pulled over by the cops for a broken tail light. He “runs your plates” before walking up to your car. He has a “red flag” pop up on his computer screen that you have diagnostic code 276 (math disorder) and he walks up to your window with his hand on his gun because, in his mind, you’ve been “flagged” as a “mentally ill person” who probably “behaves badly” even though there is no “behavior” included in the definition of code 276. My point is that “bad behavior” is being attributed to all people with diagnostic labels based on a few diagnostic labels that have “bad behavior” included in their diagnostic definition. Every person who sets foot in a psychiatrists office will be given a diagnostic label. This is a virtual guarantee. Some day all of them may end up in a blacklist.

    • Icagee,

      Thanks for commenting.

      The APA has indeed invented a “diagnosis” for every conceivable problem of thinking, feeling, or behaving. They present these “diagnoses” as if they had validity, but in reality, they just made them up. This contrasts with real medicine, where the diagnoses are discovered in nature.

      Psychiatric “diagnoses” have no value. Besides being inherently vague, they are destructive, disempowering, and – as you point out so clearly – stigmatizing.

      Best wishes.

  7. Is the point of this article that Dr. Frances is a hypocrite? Or to affirm the stigma-producing and extremely harmful idea that bad behavior indicates mental illness?

    I hope it’s the former, since it’s absurd to claim that the president can’t have narcissistic personality disorder because he doesn’t suffer from being impaired by it. It would seem difficult by definition for a narcissist to suffer from the impairments related to being a narcissist. Is “suffering from the impairments” a requirement for diagnoses of all mental illnesses? If so, it would render a lot of them invalid: does not the very diagnostic criteria of sociopathy, for example, preclude one from suffering from the distress and impairment required to diagnose mental disorder?” (That’s also, by the way, an incredibly hypocritical criteria for the psychiatry industry to maintain, but you probably know that.)

    • MRNWildhood,

      This is an interesting point, and highlights the absurdity of psychiatry’s general contention that significant problems of thinking, feeling, and/or behaving are illnesses.

      The general definition of a mental illness in successive editions of the DSM includes the requirement that the problem entails distress or disability. Neither term is formally defined, but in the psychiatric literature, the latter is often presented as synonymous with impairment in one or more areas of functioning. But the word or is critical.

      In the criteria lists for each specific mental illness, the requirement of distress or impairment is usually, though not always, re-stated. With regards to the so-called personality disorders, the opening paragraph in DSM-IV’s section on personality disorders states:

      “A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” (p 629)

      Again, note the word or. So, as you point out, a person who is markedly narcissistic might be considered impaired in his social interactions, but there is no requirement in Dr. Frances’s own DSM-IV that the individual experience any distress. The requirement is distress or impairment, but not necessarily both.

      Perhaps Dr. Frances doesn’t remember the DSM edition of which he was the architect? Incidentally, the requirements in DSM-5 are essentially the same.

      But it also needs to be noted that the issue is moot because psychiatry’s “personality disorders” have no ontological reality or validity. Discussing whether or not a person has narcissistic personality disorder is directly analogous to discussing whether a person is a witch. Neither term has any objective reference. “Mental illnesses” (including personality disorders) are simply labels, with no explanatory significance and no external validity. Their purpose is to legitimize psychiatrists’ role in the pushing of drugs.

      The essential point of my post was that Dr. Frances’s attempt to draw a clear distinction between “bad behavior” and “mental illness” is inconsistent with psychiatry’s long-standing inclusion of criminality in its formal catalog of “mental illnesses”.

      • What does this mean for pleading insanity in a court of law? What does this mean for removal of a president by 25th Amendment provisions? I am not a psychiatry apologist; I think mental illness is a social construct but I’m not willing to just throw those who are in enough mental and emotional distress to impair their functioning to the “shape-up, change-your-behavior” dogs, either. Trauma revises its sufferers physiology (ref: Bessel van der Kolk, among others); brain chemistry issues may not be the cause of mental and emotional distress, but could they not be one effect of environmental failure that provokes such distress?

        • MRNWildhood,

          You are correct in noting that there is an enormous contradiction between psychiatry’s insistence that crime is a mental illness, and their failure to promote this as, for instance, a criminal defense. In reality, they use “conduct disorder”, “antisocial personality disorder”, and other “diagnoses” that consist essentially of criminal acts, as gateway diagnoses, to bring in business, but they systematically ignore the ramifications of this, presumably because they realize that such efforts would shatter what little credibility they have.

          You point out that “trauma revises its sufferers’ physiology”, and of course this is true. All human experience revises our physiology to a greater or lesser degree. But I’ve certainly never advocated throwing anybody to what you describe as the “shape-up, change-your-behavior dogs”.

          I think we should all try to help one another, both individually and through our social, political, and economic institutions. And the best way to help people who are depressed, for instance, is to help them identify the sources of the depression and help the individual resolve these matters. As obvious as such an approach is, it is almost never adopted by psychiatrists, who instead push dangerous drugs to numb the distress, while leaving the source(s) of the problem intact.

          Similar observations can be made about the other problems that psychiatry has spuriously medicalized.

          • The problem is that, if we’re really honest about the causes of depression (and anxiety and panic and other distress), *individuals* really can’t resolve them because mental illness is a social construct – which I take to mean, an indication of failed environments rather than “made up” names and labels. We would have to work together to change society and culture, and in this society of rabid individualism, I’m not holding my breath for that.

  8. Yes. And yes.

    Philip Hickey and many of us here including me, believe “mental illnesses” exist only as social constructs. Therefore you might make the case for Pres. Trump or anyone as morally misbehaving but there is no neurological or genetic disorder responsible. Instead of “narcissistic personality disorder” we would say conceited jerk.

    As long as we consider the DSM to be a valid scientific document there will be no hope for ending the discrimination called “stigma.” And people with periods of intense sadness, mood swings, and other problems will adopt childish, fatalistic attitudes making change impossible. (After 25 years in the psych system I have learned to take responsibility for my actions or “grown up.” Leaving it was necessary for this to happen.)

    Biological determinism is counter-productive, both in causing positive social change or making good life choices on the personal level.

    Now you know what MIA is about in a not-to-long summary, Wildwood. It is a major paradigm shift and difficult to accept–at first. It does run against the cultural narrative that certain people are doomed to lives of hopeless insanity and can never learn self control or responsibility. Some never can accept this counter-cultural idea. If you are one of those, you will not be the only dissident subscriber. 🙂

  9. I’m aware of what MIA is about (and am vehemently against the biomedical model), but wait: by “yes and yes,” you’re saying that this article *IS* to affirm the idea that bad behavior indicates mental illness. That contradicts the rest of your comment so I’m a little confused.

    Also, the whole “make better choices” story I see coming up in the comments is a little worrisome. Mental illness is a social construct – as in, an environmental failure. Poverty, racism, sexism, abuse, trauma, are sometimes spirit-breaking things to live through. Telling people to make better choices or grow up feels like victim blaming to me. It’s not that people are not responsible for their actions, but people function better when they’re loved and have supportive environments. This country doesn’t foster either of those things for most people.

        • I would never give someone in your situation that advice, Francesca. Some whiners on psych forums (soft labels like severe depression) enjoy their “illnesses” and have fits of rage if you suggest they have any control of their feelings/thoughts/behaviors at all.

          They seem proud of having real honest-to-gosh brain diseases so they can do nothing but sit around pill popping. They enjoy their uppers and go around swearing “I found salvation in a bottle of Zoloft!” This sounds more like religious testimonials than medical reviews.

          When used on yourself this can work. Only the person doing this motivational speech on him/herself can judge its effectiveness. If it makes you more depressed it’s not working. Go easy on yourself instead. 🙂

    • Two things should be pointed out here:

      1. Are we dealing with “mental illness” as “brain disease” or “behavioral deviance”? “Brain disease” is a matter of biology. “Deviant behavior”, of conscious choice, barring interpretations based on Neo-Freudian theory and speculation. We have laws for actual “bad behavior”. “Bad behavior” that doesn’t break any laws perhaps we can tolerate. There are more than enough stupid laws on the books already to go around.

      2. Allen Frances, in the context of this post, is defending Donald Trump from the “mental illness” label, given his reputedly “bad” behavior, while applying the same label to the American public. Huh!? One almost has to have a double take on the matter. What, for instance, did the American public do to deserve, or earn, if one prefers, such labeling?

      One could call, as has and is being done, psychological “distress” “mental disease” or “disorder”. The problem involves this two-fold process, labeling “distress”, a very human phenomenon, and pathologizing “bad” behavior. Both would tend to turn non-medical problems over to the medical community. When it comes down it, I imagine it would be “easier” to “heal” (or “treat”) Donald Trump than it would be to “correct” the American public.