I have written a book that explains why we use vaccines to prevent disease. I have also written a book about mental illnesses: what they are and how they are classified, diagnosed, and treated. So I am well prepared to answer a common question: are the antivaccine zealots out of their minds? The answer is “sometimes”; that determination must be made on a case-by-case basis. Vaccination has long been the mainstay of public health efforts. Being vehemently opposed to the mainstay of public health efforts is not, per se, a mental illness. But neither is it a sign of good mental health, especially not in an educated person. In fact, people who go to great lengths in their antivaccine advocacy are more likely than the average person to have a particular kind of mental illness: a personality disorder.
What Is a Personality Disorder?
Psychiatrists are not supposed to give people a diagnosis of mental illness just for holding false beliefs. It is normal for people to hold some false beliefs. Normal people tend to hold the same false beliefs as their friends and relatives. Nevertheless, the thought processes that lead someone to embrace and spread falsehoods are definitely faulty. If someone’s faulty thought patterns, groundless fear, and dysfunctional behavior are causing disability and suffering, they do constitute a mental illness. If those thoughts, feelings, and behavior are different from what one would expect for the person, given that person’s social background, they could even qualify for a diagnosis of a psychiatric disorder. If those dysfunctional ways of thinking and relating to the world, and to the other people in it, are long-standing and pervade many aspects of the person’s life, they may even qualify for a diagnosis of a kind of mental illness called a personality disorder.
How Mental Illnesses Are Classified
In my book Don’t Feed the Narcissists! The Mythology and Science of Mental Health, I explain that a mental illness can be any problem in the realm of cognition (which means perception and thoughts), emotion, and/or action. Each mental illness is likely to have some manifestations is all three areas. Psychiatrists classify mental illnesses according to the area in which the problem is most obvious. If the person’s most obvious problem in the realm of cognition (perceptions and thought patterns), the person is said to have a psychosis. If the most obvious problem is in the realm of emotions, the person is said to have a mood disorder. If the most obvious problem is a longstanding pattern of odd or bad behavior, the psychiatrist may consider the diagnosis of a personality disorder. People with personality disorders also have problems with thinking and mood. Those problems may be serious; however, they are less obvious than the person’s odd or bad behavior.
Cluster A, B, and C Personality Disorders
The American Psychiatric Association’s Diagnostic and Statistical Manual provides the diagnostic criteria for many different mental illnesses. It defines ten personality disorders, which are divided into three clusters: A, B, and C. The cluster A personality disorders involve problems in how the person relates to reality. The cluster B personality disorders involve problems in how the person relates to other people. The cluster C personality disorders involve problems in how the person deals with fear. The symptoms of the disorders within a particular cluster often overlap. Also, a person can have a diagnosis from more than one cluster. Also, the problems in one area can reinforce problems in the other area. Mood disorders and behavior disorders are often rooted in problems with logical reasoning.
How Personality Disorders Shape Beliefs and Actions
The personality disorders can provide a useful framework for understanding why someone would become an antivaccination zealot. Like people with a cluster A personality disorder, antivaccine zealots have difficulty in using evidence to evaluate the soundness of their ideas, and they may have a deep-seated irrational suspicion of other people’s motives. Like people with a cluster B personality disorder, many antivaccine zealots like to create drama and strife, to draw attention to themselves, to dominate others socially, or to exploit others personally and financially. Like people with a cluster C personality disorder, especially obsessive-compulsive personality disorder, many antivaccine zealots have deep-seated irrational fears of becoming contaminated, and they may have a strong inertia bias: they would rather accept serious risk by doing nothing, rather than assume a minor risk by taking some sort of positive action.
Disability and Suffering
A diagnosis of a personality disorder is based primarily on the person’s behavior. Their behavior must be not only unusual but dysfunctional—causing disability and/or suffering for themselves or suffering for other people. To qualify for a diagnosis of a personality disorder, the person must have a history of dysfunctional behavior that started early in life, that pervades many areas of the person’s life, and that seems to be resistant to correction. The fact that the pattern of dysfunctional behavior started early, is pervasive, and is resistant to correction suggest that the underlying problem in cases of personality disorder is a failure to grow up emotionally—especially since the behaviors in question would often be perfectly normal for a much younger person. Just as the storybook character Peter Pan still had his baby teeth, people with personality disorders are trying to get through adult life with coping skills that worked well when they were toddlers but are inappropriate for adults. By studying people with personality disorders, you can learn lessons about how to grow up yourself. Just get really good at the things that people with personality disorders do poorly.
Worries About Vaccines
Many people are worried about whether vaccines are necessary and safe. This worry is understandable, given the increasingly commercial nature of healthcare in contemporary capitalism. Yet for reasonable people, concerns about vaccination can be quickly and easily dispelled through consumer education. Yet for the die-hard antivax zealots, no attempt at persuasion will work. At best, they will tell you that they have decided to “agree to disagree.” At worst, they will become personally abusive to anyone who tries to reason with them.
How People Choose Their Talking Points
When you ask antivaccine zealots why they are against vaccines, they express concerns that fall neatly into the A, B, and C clusters and sometimes align with a particular personality disorder. Expressing one of these concerns does not mean that you have the corresponding personality disorder. But if you do have a personality disorder, you are likely to embrace the antivaccine talking points that align with your personality disorder.
Cluster A personality disorders (problems in the relationship with reality)
- A stated preference for some mystical or magical alternative, such as homeopathy or energy healing (schizotypal personality disorder).
- Concern that an evil conspiracy is putting poisons in the vaccines in order to sterilize children or cause genocide or depopulation (paranoid personality disorder).
- Belief that vaccines are part of an attempt to exert mind control on the population (paranoid personality disorder).
Cluster B personality disorders (problems in relationships with other people)
- The use of antivaccine advocacy to seek attention for its own sake (histrionic personality disorder).
- The desire to portray oneself as superior to medical doctors and the world’s top experts on biology and medicine and public health (narcissistic personality disorder).
- The belief that because of their close personal relationship with Jesus Christ, God would not allow any of their children to become sick (narcissistic personality disorder).
- Belief that vaccination would be unnecessary because of one’s exceptional parenting skills—breast-feeding, home cooking, etc. (narcissistic personality disorder).
- A desire to discredit real doctors and real medicine in order to sell some bogus “alternative” product or service, such as naturopathy, homeopathy, or herbal medicine (antisocial personality disorder).
- A need to create drama in interpersonal relationships by arguing about nonsense (borderline personality disorder).
Cluster C personality disorders (problems with fear)
- A desire to avoid doing anything that sounds even remotely risky (avoidant personality disorder).
- A desire to submit to and obey some charismatic leader, such as a pastor or alternative health practitioner (dependent personality disorder).
- Fear of contamination because of the scary-sounding ingredients or trace contaminants in vaccines (obsessive-compulsive personality disorder).
Psychosis or Personality Disorder?
People with personality disorders have problems with how they perceive the world and how they think, but those problems are not severe enough for them to qualify for a diagnosis of a psychosis. People with personality disorders tend to have unusually poor judgment. They are poor judges of the truth of ideas. They are poor judges of other people. They are poor judges of themselves. If you try to reason with someone with a personality disorder about their antivaccination ideology, you will run smack into their judgment problem. Nothing you can say will make a difference, precisely because their judgement is so poor that they do not realize that their judgment is poor. (In psychology, this is called the Dunning-Kruger effect.)
Diagnosing Personality Disorder
How do psychiatrists decide if a patient has a personality disorder? One of the biggest difficulties in psychiatry is drawing the line between normal and abnormal, and between healthy and ill. Those are actually two separate challenges. People who have abnormally good skills in some area are, by definition, abnormal—but this departure from normality does not mean that they are ill. Also, normality itself is not necessarily good. For example, in some social circles, it is perfectly normal to embrace certain irrational beliefs and to behave badly. To qualify for a diagnosis of a personality disorder from a psychiatrist, your coping skills and behavior have to be more than just bad. They have to be remarkably and consistently bad, so much so that you are not functioning normally within your society.
The Cause of Personality Disorder
What causes personality disorders? Nobody really knows. In the early 20th century, German psychiatrist Emil Kraepelin believed that the severe forms of mental illnesses, including the psychoses and the personality disorders, were probably rooted in disease of the brain, which could sometimes be genetic. (Of course, as soon as the medical cause of a particular mental disorder is discovered, the disorder gets reclassified, often as a neurologic disorder as opposed to a psychiatric disorder.) At the same time, Sigmund Freud was popularizing psychoanalysis, which focused on the presumed psychological causes of mental illnesses. Psychological explanations are probably adequate for most of the mild, common problems that can be solved through talk therapy. Any given case of mental illness could have some combination of medical and psychological causes. The more severe the illness is, the more likely it is that there is a medical component. Yet even if there is a strong medical component, the person may still benefit from talk therapy, to help them learn to cope with or even compensate for their brain problem.
How to Outgrow a Personality Disorder
Each of the three clusters of personality disorders represents a failure to meet a particular kind of challenge that adults are expected to meet. People with cluster A personality disorders engage in magical thinking because they lack mature skills in reality testing. People with cluster B personality disorders don’t know how they fit into society. As a result, they behave like toddlers or teenagers instead of like adults. People with cluster C personality disorders do not know how to manage fear. As a result, they either become childishly dependent or go overboard in trying to control things. Ideally, our educational system would help people develop the skills they need for adult life. Psychotherapy could help them learn the lessons that they missed in school.
Cluster A Disorders and Reality Testing
Reality testing means “the objective evaluation of an emotion or thought against real life, as a faculty present in normal individuals but defective in psychotics.” Of course, it is natural and normal to have mediocre skills at reality testing. That’s why superstitions (false beliefs about cause and effect) are common, especially among the poorly educated. Ideally, the purpose of a science education would be to help people develop good skills in reality testing. Unfortunately, science classes are often focused exclusively on getting students to cram a set of disconnected facts into their short-term memory. As a result, the students do not develop the skills in reality testing that they will need in adult life. Nor do they even retain many of the facts that they were supposed to memorize. To improve your own skills in reality testing, read some books on logic and about the history of science. Learn about how and why the current scientific theories were developed, and why the obsolete ones were discarded.
Cluster B Disoders and Fitting Into Society
The Cluster B personality disorders are problems in how people relate to other people. People with histrionic personality disorder use attention-seeking as a way to solve problems. Like a newborn, they cry for attention, so that higher-ranking people will solve their problems for them. For histrionic people, antivaccine advocacy can be a way to seek attention. People with narcissistic personality disorder try to use dominance as a way to solve problems. They want to be regarded as the best and the brightest, so that other people will serve them. However, other people may not admire the narcissists as much as narcissists admire themselves, and narcissists are trying to occupy a higher social position than they can handle responsibly. Narcissists want to occupy the role of wise elder, but they do not have the knowledge or judgment to fulfill that role. For example, a narcissist may want to be regarded as an expert on all aspects of health, even if he or she has never taken even an introductory college-level course in biology or nursing. As a result, they often give foolish, dangerous advice. People with antisocial personality disorder view other people as objects to be used and exploited, not as fellow human beings whose joys and sorrows are to be shared. These sociopaths may get involved in antivaccine advocacy as a way to market useless goods and services. People with borderline personality disorder have problems with regulating their emotions. They desperately seek close relationships but then deliberately do things that drive people away. Arguing over things like vaccination would be a perfect way to create this kind of drama.
Cluster C disorders and Handling Fear
Fear is the primitive emotion that we feel when we think that our bodies or our feelings might get hurt. The natural reaction to fear is avoidance. This is a major reason why people refuse vaccination. They are afraid of needles, and they are afraid of the scary-sounding ingredients in the vaccine. Anything that increases the person’s sense of fear could make them even more avoidant. That’s why attempts to educate people about the dangers of the vaccine-preventable diseases can backfire. By intensifying the person’s fear, you make them even more avoidant. They become so terrified that they freeze in panic. Terrified people often refuse to take any action, even to run to safety. For this reason, any public relations campaign to promote vaccination should be carefully tested, to make sure that it does not accidentally increase resistance to vaccination.
To Solve Vaccine Disputes, Eradicate the Diseases
The antivaccine movement is creating problems on two time-scales. In the short run, it is leading to outbreaks of serious diseases, such as measles and pertussis, as well as sporadic cases of tetanus. In the long run, the antivaccine movement is undermining efforts to drive some of the vaccine-preventable diseases into extinction. A global vaccination campaign drove smallpox into extinction in the 1970s. A similar campaign has already wiped out two of the three strains of wild poliovirus. Many of the other vaccine-preventable diseases can also be eradicated because they occur only in human beings. And once a disease is extinct, we can safely stop vaccinating against it.
Why Do We Vaccinate?
Vaccines are used to prevent diseases that are serious because they are caused by germs that are good at getting past the body’s innate immune system but that can be controlled by the body’s adaptive immune system. The innate immune system is the general-purpose response to any infection. In contrast, the adaptive immune response is a custom-tailored response to a particular infection. We use vaccines to prevent the diseases can cause serious illness, permanent disability, or even death before the body’s adaptive immune system develops the ability to fight them. The purpose of vaccination is to give the adaptive immune system a head start, so that it can recognize and fight the infection before it takes hold. Many of the germs that are really good at getting past the innate immune system are so highly adapted to living in the human body that they are found nowhere else in nature. Once we stop those germs from circulating in the human population, they go extinct. At that point, we don’t need to vaccinate anyone against them anymore.
Let’s Focus on Disease Eradication
The measles vaccine was introduced in the 1960s, and the United States eliminated measles in 2000. This meant that the measles virus was no longer circulating within the U.S. population. Yet we would still have a few cases every year, brought in by travelers who caught measles in areas where measles is still circulating. So to wipe out measles, we need to wipe it out worldwide. By focusing on disease eradication, we can make it clear that the purpose of vaccination is to promote public health, not private profit. As soon as a disease is eradicated, sales of the vaccine to prevent it drop to zero and will remain zero forever. So disease eradication would be a bad investment for a “pharma bro.” Disease eradication has another important benefit. Once a disease is eradicated, we no longer have to frustrating conversations about that disease with ill-mannered people who think that they know more than the experts.