The Pistorius Disorder


Re the trial of Oscar Pistorius for the murder of Reeva Steenkamp, Judge Thokozile Masipa, will render her verdict on September 11. This post reflects on the influence of the Diagnostic and Statistical Manual of Mental Disorders on the trial.

The court has been presented with two competing explanations of what happened that night. Either:

Years of accumulated stress caused by the amputation of both legs beneath the knee bestowed Pistorius with a capacity to respond to threatening situations in a certain way. On that fateful night that capacity was triggered by a startling noise coming from the bathroom. He thought he was in danger, an intruder was coming out of the toilet. He responded to the noise, as if by reflex, by squeezing the trigger of the Taurus PT92 9mm in his hand four times: one … two … three … four. If it was a reflex action, he lacked criminal intent. If there was thought involved at all, it was a thought of danger, he acted in self-defence. Barry Roux likened Pistorius to the ‘slow burn’ of anxiety suffered by an abused woman who had finally ‘had enough’ and kills her husband. He had no motive for killing Reeva. They were in a ‘loving relationship’. The Report by the clinical psychologist confirms this.


Pistorius shot Reeva in a jealous rage. Jealousy is a volatile combination of fear and anger. Fear of losing her. Anger at the effrontery of it. He shot her to stop her leaving him, that night, for ever.

They had a row. Neighbours heard raised voices. Just weeks before, she told him she was afraid of him sometimes. This was one of those times. She sought sanctuary in the toilet and locked the door, cell phone in hand. They were talking up to the time he killed her.

It was premeditated murder. There was no intruder, real or imagined. He knew that Reeva was behind that door and he knew the consequences for her of his armed rage. The consequences of the act for him hit home immediately his rage was satiated by her death. Immediately, the ‘intruder’ was born. Every event leading up to her death had to be rendered consistent with this improbable premise.

The pivot linking these two scenarios is the mental health of Pistorius and his capacity for criminal responsibility. To settle this matter, a panel comprised of a clinical psychologist and three psychiatrists was established . It submitted its report to the court the week beginning June 30th and it was accepted with little comment by defence and prosecution counsels.

Note, however, that to decide if Pistorius was criminally responsible for his actions when he shot and killed Reeva Steenkamp, the four learned gentlemen subjected Pistorius to a full-blown examination and what that revealed comes attached to the answer to the simple question asked of them. It is likely to have a major bearing on the court’s verdict and sentencing. It favours the defence. Here I show how by critically examining the Report.

The Testimony of Dr. Merryl Vorster

The commissioning of an evaluation of the state of mind of Pistorius was triggered by the testimony on May 12th, of Dr. Merryl Vorster, a forensic psychiatrist and vice-dean at The University of the Witwatersrand. Dr. Vorster had been asked by the defence to evaluate the mental condition of Pistorius and his likely condition at the time of the shooting. She interviewed Pistorius, his friends and family between May 2 and 7 this year, the defendant had completed five days of testimony.

The commissioning of an evaluation of the state of mind of Pistorius was triggered by the testimony on May 12th, of Dr. Merryl Vorster, a forensic psychiatrist and vice-dean at The University of the Witwatersrand. Dr. Vorster had been asked by the defence to evaluate the mental condition of Pistorius and his likely condition at the time of the shooting. She interviewed Pistorius, his friends and family between May 2 and 7 this year, after the defendant had completed five days of testimony.

She concluded that Pistorius suffers from Generalized Anxiety Disorder (GAD) and that this disorder was caused by a combination of: (a) the amputation of his lower legs when he was less than a year old; (b) his parents’ divorce when he as a child; (c) the stress of his growing fame. Or as ABC News put it: ‘Oscar Pistorius’ Shrink Says Leg Amputations Gave Him Mental Disorder’. Dr. Vorster said his actions on the night of the murder, February 14, 2013, ‘should be seen in context of his anxiety.’ She added that someone with his level of anxiety and access to guns would be a danger to society. Her testimony raised the question, Was Pistorius responsible for his actions and capable of distinguishing between right and wrong that fateful night. Or did GAD make him do it? To have this question answered, prosecutor Gerrie Nel asked the court to have Pistorius undergo psychiatric evaluation. Barrie Roux for the defence vehemently objected. Judge Masipa granted Nel’s request. Pistorius was assessed as an outpatient over 30 days at Weskoppies psychiatric hospital in Pretoria (originally the Pretoria Lunatic Asylum.)

Pistorius was examined by a clinical psychologist (Professor J.G. Scholtz) and three psychiatrists (Dr. C. Kotze, Dr. L. Fine, and Professor H.W. Pretorius). Their deliberations produced a Forensic Psychological Report (30 pages) and a Psychiatric Report (one page). The common brief of this single psychologist and triad of psychiatrists (the ‘panel’) was to determine if Pistorius, at the time of the offence: (a) suffered from a mental illness or defect such as to prevent him being criminally responsible, and (b) was capable of appreciating the wrongfulness of his act and acting in accordance with that appreciation. The short answer of all four was, No and Yes. But the long answer suggests the contrary.

There are actually two reports, then, not one; they were submitted to the court the week of June 30th. Presumably they are to be considered together, even though they reach different conclusions. Although the presiding judge prohibited their publication, they found their way on to social media and the defence belatedly blessed their release. As well they might.

The Psychiatric Report

The Psychiatric Report is but one page. It states conclusions and is silent on how they were reached. Key findings:

  1. Pistorius ‘did not suffer from a mental disorder at time of shooting’.
  2. ‘Currently the accused presents with an Adjustment Disorder with mixed anxiety and depressed mood that developed after the alleged incident.’ (my emphasis)
  3. He was not unable to understand the difference between right and wrong, or to act on that understanding.

This is contrary to Dr. Vorster’s testimony, in two respects: First, whereas she stated that Pistorius did suffer from a mental disorder at the time of the shooting, these three psychiatrists maintain that he did not. Second, whereas she stated that Pistorius suffers from Generalized Anxiety Disorder, these three psychiatrists maintain that he suffers from an Adjustment Disorder.

Like all ‘disorders’, Adjustment Disorder is a creation of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. It is a label applied by a mental health practitioner to a person who is adjudged to suffer from acute and chronic psycho-social stress to which they are unable to ‘adjust’.

The Psychiatric Report implies that the psycho-social stressor for Pistorius is the ‘alleged incident’ and his trial for being its cause, Steenkamp’s murderer. This is a rather odd kind of adjustment disorder. Who would not feel anxious and depressed about killing someone (intentionally or not) and then being tried for their murder with the prospect of spending the rest of their life incarcerated. Who would not have difficulty adjusting to this situation? Surely, to react in this way is a normal reaction to a pathological situation, not a ‘disorder’.

This psychiatric triad are able to apply this category to Pistorius only because the DSM’s criteria for Adjustment Disorder are so vague as to render the very category a dubious, discredited disorder. An ‘Adjustment Disorder with mixed anxiety and depressed mood’ sounds like a weather forecast; ‘thunder storms with outbreaks of sunshine and a sprinkling of scattered showers.’ It anticipates just about every eventuality. It’s a ‘safe’ diagnosis. That this Psychiatric Report disagrees with that issued by earlier by Professor M. Vorster, which diagnosed Pistorius with Generalized Anxiety Disorder, may not amount to much of a difference. The borderline between the criteria for AD and GAD is paper thin and where one draws that line is largely a matter of taste—or expediency. With one important difference. The ‘adjustment’ of Adjustment Disorder entails that Pistorius was normal on the night in question. The ‘general’ of Generalized Anxiety Disorder implies that the disorder preceded the murder.

The conceptual incoherence of ‘Adjustment Disorder’ is evident in the thoughtless imprecision of the writing in the Psychiatric Report. ‘Alleged incident’? Are these psychiatrists denying that Ms Steenkamp was murdered? Or it is simply in bad taste to be so blunt? Presumably they mean his alleged guilt, but this is hardly an ‘incident.’

The Forensic Psychological Report (Professor Scholtz)

This is a much more substantial report. (Unusually, in two places the date of the murder is stated as 14th February, 2014.) Professor Scholtz diagnosed yet another disorder in Pistorius. Key findings:

  1. ‘ Pistorius has been severely traumatized by the events that took place on the 14th of February 2014 (sic should be 2013).
  2. He currently suffers from a Posttraumatic Stress Disorder and a Major Depressive Disorder as defined by the Diagnostic and Statistical manual-5 (DSM-5).
  • The degree of anxiety and depression that is present is ‘’
  1. He is also ‘mourning the loss of Ms Steenkamp.’ (p. 29).
  2. ‘ Pistorius is being treated and should continue to receive clinical care by a Psychiatrist and a Clinical Psychologist for his current condition. Should he not receive proper clinical care his condition is likely to worsen and increase the risk for suicide.’ (p. 29) Elsewhere he adds that this risk is mitigated by his Christian beliefs and close family ties.
  3. ‘No evidence could be found to indicate that Mr. Pistorius has a history of abnormal aggression or explosive violence. Abnormal aggression and violence was never incorporated into his personality, as borne out by both psychometric testing and collateral information.’ (p. 29). Pistorius is ‘respectful, gentle and conflict-avoiding’.
  • ‘There is evidence to suggest that Mr. Pistorius does have a history of feeling insecure and vulnerable, especially when he is without his prostheses. He has also been exposed to crime directly or indirectly throughout his life.’
  • Contrary to Professor Vorster’s finding: ‘He specifically does not meet criteria “D” of the DSM-5 for Generalized Anxiety Disorder, that is ‘The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.’ If his context is taken into account his functioning was superior prior to the incident in February 2014 (sic)’ (p. 30)
  1. ‘There is evidence to suggest that Mr. Pistorius was genuine with his feelings towards Ms Steenkamp and that they had a normal, loving relationship.’

How were these findings made?

  1. Pistorius was physically examined; his blood was tested, the electrical activity in his brain was measured.
  2. He was interviewed (for 19 hours) and his general behaviour was observed. Significant people in his life were also interviewed. Out of these interviews Professor Scholtz reconstructed the life of Pistorius in narrative form. (See the section ’History and development of Mr. Pistorius’.)
  3. He was subject to a psychometric assessment: his knowledge and skills, abilities and attitudes, and personality were objectively measured. Pistorius completed the Psychiatric Diagnostic Screening Questionnaire (PDSQ): ‘an instrument that serves as a screening test for the presence of clinical conditions as defined by the Diagnostic and Statistical Manual-4.’ (p. 16)

Gerrie Nel, reading from the Report, grasped at the following sentence, as if to say, ‘this is the bit that matters’:

Mr Pistorius did not suffer from a mental illness or defect that would have rendered him criminally not responsible for the offence charged.

However, all of this report matters, not just the bits that conclude that he is criminally responsible or, as Professor Scholtz puts it, ‘not … criminally not responsible…’

The section of the Forensic Psychological Report entitled ‘History and development of Mr. Pistorius’ is a narrative reconstruction of his life based on 19 hours of interviews with him and people familiar with him. Their identities are redacted. Pistorius provided the raw material and Professor Scholtz wove it into a plausible narrative. ‘As told to …’ ‘He reported’. ‘He denied.’ ‘He reports no’. ‘He stated no.’ However, what actually happened in a person’s past life and how that person remembers what happened may be entirely different things. They usually are. This is why auto-biographies are often regarded as works of fiction. However, narratives don’t have to be true to be believed, they just have to be plausible.

‘History and development of Mr. Pistorius’ is the basis of the section entitled ‘Integration and formulation’. This is speculation built on fancy. Consider (all emphases are mine):

  • Pistorius ‘faced strong challenges from the time he was born.’ So do many people, especially those with disabilities, but why is this remarkable?
  • ‘This might have made his attachment with his mother an anxious one, leaving him to try and self-sooth ….’ (p. 23)
  • ‘it seems he was born with a strong fighting spirit …’
  • ‘He was a happy, contented baby …’ How can Professor Scholtz be so certain of this?
  • ‘his mother was able to overcome her initial reaction and that he then had a good bonding with her. She was able to externalize her emotions in a normal manner ….’ His mother is long dead, so how does the learned professor know this with such certainty.
  • She passed on to ‘ Pistorius the rudimentary “blueprint” of affect regulation.’
  • His bilateral amputation at 11 months would have been’ This is hotly contested.
  • ‘It is possible that a “blueprint” of mistrust, insecurity and being unsafe was already laid down at that stage of his personality development …’
  • ‘He would have experienced fear and anger and felt abandoned by her. This would have challenged his ability to view her as an integrated whole person, both good and bad.’
  • ‘It is also possible that his mother “usurped” him [the father] out of guilt, pulling him further away from his father.’
  • ‘His mother was a devout Christian and had instilled these values in him’ (p. 24). Not everyone regards this as a good thing. As one commentator put it, Pistorius’s behaviour was typical of ‘young Afrikaner men who are brought up in the Calvinist religion.’
  • ‘ Pistorius realized that many women wanted to be with him because of his fame’ (p. 24). Here, Professor Scholtz informs us of what Pistorius—on trial for the murder of his girl friend—‘realized’ about women.
  • ‘The approach of his mother to his disability probably enabled him to complete his next phase of development (approximately age 2-6 years) successfully, perhaps too much so.’
  • She had an attitude of …’ ‘She would tell him and his brother to …’ She did not make a distinction between him and his brother because of his disability.
  • ‘It was probably at this point that he …’
  • There two Oscars: ‘The one a vulnerable, scared disabled person, the other a strong physical person achieving beyond expectation and finding rewarded (sic) for it both intra-psychically and interpersonally.’ Here Professor Scholtz reports his discovery of the ‘divided self’ of Pistorius.
  • The account of his ‘traumatic’ experience at age 7/8 is all from Pistorius. ‘… he was terrified’. (p. 25)
  • ‘The impact of losing these male figures in his life at the beginning of adolescence was strong. Feelings of insecurity and the sense of a foreshortened future are some of the aspects often described for a boy in that situation.’
  • ‘He had adapted well to high school, made good friends …’ (p. 26).
  • ‘In spite of the challenges Mr. Pistorius got involved in various projects to help other people in this time, especially those less fortunate with him. He would always make time for his fans and handled himself with aplomb in most stressful situations.’

What Professor Scholtz does here is reconstruct the life of Oscar Pistorius on the basis of what he has told him in interviews. Essentially, Pistorius testifies in his own defence in these interviews and without cross-examination: Scholtz seems to have accepted uncritically every statement and claim Pistorius made. In accepting this Report the court has accepted it uncritically too. Pistorius gets to testify twice, this time without cross-examination.

Professor Scholtz is influenced by object relations theory. This tells us what will happen in an ideal typical or paradigmatic case. Where the theory and Pistorius’s account of himself match, the good professor records it as fact.

Professor Scholtz concludes that Pistorius was traumatized by the murder of Steencamp. Hence the diagnosis of Post-traumatic stress disorder, depression and grief. Isn’t this a little odd? Surely only an innocent person can be feel grief and be traumatized by the murder of his girlfriend? This is certainly what this Report implies, intentionally or not. Is such a person not deserving of our sympathy and care, especially so since they are in danger of becoming a suicide risk? This is like the story of the boy who murdered his parents and then argued that he deserved clemency because he was an orphan.

There is, surely, another interpretation of Pistorius’s ‘grief’ and ‘trauma’. A man moved by a jealous rage can harm his girl friend and immediately be full of remorse at what he has done; for he acted only with the best of intentions, you understand, out of (some kind of) love. It happens all the time. If Pistorius did indeed kill Steenkamp in a murderous rage, would he not feel remorse, guilt, shame and fear of being punished? In this sense, he would be the cause of his own effect, his own trauma. How would one distinguish between these feelings and their associated behaviours and the criteria of PTSD?

Perhaps these experiences of suffering, picked up by Professor Schultz, are not a disorder at all, but an entirely appropriate response to his actions. What if his suffering is actually deserved? Feeling bad when we’ve done something bad is no ‘disorder’: it’s moral behaviour. The DSM, however, does not allow for this possibility because it presumes that all suffers of PTSD are innocent. They suffer because of what was done to them or what they were forced to witness, never because of the horror of what they chose to do to others, made others witness.

The Reports in Court

Defence and prosecution counsels took from these two Reports that which supports their case. Both noted that both Reports show the athlete’s psychological issues manifested after the shooting, not before.

Defence Advocate Barry Roux noted that:

  • Pistorius has no history of abnormal aggression of violence or traits of narcissism;
  • the trauma of that night and its aftermath left him with Post Traumatic Stress Disorder and depression;
  • he is at risk of suicide if his condition is not treated;
  • there is evidence that Pistorius shared a loving relationship with Steenkamp. As if people in ‘loving relationships’ are not capable of harming each other. ‘Love’ is usually the source of the violence.

State Prosecutor Gerrie Nel read excerpts from the Psychiatric Report and noted that Pistorius suffers from an adjustment disorder, anxiety and depression, and underlined that these conditions developed after he killed Reeva Steenkamp.

These diagnoses matter because they have implications for the ‘reasonableness’ of his actions, and this is situational. It’s not just a matter of being able to know right from wrong, it’s also a matter of what Pistorius regarded as right and wrong in those circumstances and this depends on the nature of his ‘disorder’.

A diagnosis of GAD points to culpable homicide, rather than murder or premeditated murder; a man with an anxiety disorder responds in an entirely different way to a normal person.

A diagnosis of PTSD implies his innocence for, according to this category of the DSM, trauma is a result of something that has been done to oneself or been forced to witness. One cannot traumatize oneself.

A diagnosis of AD also points to his innocence. It suggests that Pistorius’s symptoms are not a normal reaction to a pathological event, but a pathological reaction to something he witnessed.

Pistorius’s Place in the Taxonomy of Mental Disorders

Every single step in all three reports leads to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Put another way, every measure, every observation, every inference about Pistorius is weighted according to the specific gravity of the APA’s DSM.

Here I want to draw attention to the following.

  1. The DSM is a taxonomy of mental ‘disorders’. It classifies clusters of symptoms or effects solely in terms of the behaviour exhibited.
  2. This is a problem because symptoms alone rarely indicate how a malady should be treated. For that one needs to know what causes it. Despite the ‘diagnostic’ in its name, the DSM has little to say on the causes of ‘mental disorders’.
  • For the DSM, different people can display identical symptoms in response to very different causes and end up in the same classification. And different people can display very different symptoms in response to identical causes and end up in different classifications.
  1. This isn’t a problem for the DSM because it is a taxonomy of disorders, not a handbook of how to get well.

Humans are a social species. ‘Mental’ problems often have social roots in how and with whom we live. ‘Mental disorders’ are often connected to ‘problems in living’. Remedy the ‘disorder’ by helping people change their social circumstances.

The DSM doesn’t recognize the connection between mental and social problems because it abstracts the body from its social context and the brain from the body. This is how ailments that inhabit the entire body and its social roots are transformed into ‘mental’ illnesses.

For the American Psychological Association and its Manual, just as for their psychiatrist and psychologist clients, there are no causes to be solved by changing how people live, only symptoms to be managed pharmaceutically. This is true even of psychiatrists, or, perhaps, especially true.

That three separate examinations can determine that Pistorius displays behaviour consistent with the criteria of three different disorders, General Anxiety Disorder, Post-traumatic Stress Disorder, and Adaption Disorder, should cause us to take pause. Depending on which category we adopt:

  1. Pistorius developed a mental disorder from an early age because his lower legs were amputated.
  2. Actually no. His mental disorder was caused by the trauma of the Steenkamp’s murder.
  3. Pistorius was so anxious that he was a danger to society when in possession of a gun.
  4. No he wasn’ Abnormal aggression and violence were never incorporated into his personality—psychometric testing and collateral informations tells us so. Pistorius is ‘respectful, gentle and conflict-avoiding’.

Perhaps his assessors cannot agree on a classifications because the characteristics Pistorius ‘presents’ to his esteemed clinicians are not mental disorders at all but normal responses to what he has done.

The categories and criteria of the DSM have little to do with actual social-somatic people. It is a taxonomic net to be thrown over whomsoever has the misfortune to come its way. The DSM doesn’t even care what country you live in. Why is a manual of the American Psychiatric Association being used to diagnose the health of this South African? The answer: Because the DSM is not actually interested in real people and their concrete circumstances, only in categorizing their behaviours according to its taxonomy, where people live is immaterial. A corollary of this violent abstraction is that those who inhabit these ‘disorders’ are presumed to act in the same way in similar circumstances, as if they lacked all moral agency.

‘I’m Not Disabled. I Just Don’t Have Any Legs’

We might quibble with a a clinical psychiatrist, a clinical psychologist, and a group of three psychiatrists, who each come to different conclusions about Pistorius, but what of the orthopaedic surgeon Dr Gerry Versveld who removed Pistorius’ lower legs when he was a very young child? Dr. Versveld was called by the defence to give his testimony.

It can be summarized thus. Because he lacks lower legs, Pistorius lacks maneuverability and stability; he is liable to fall over. Because he lacks maneuverability and stability, he is vulnerable to attack in some situations. Because he is vulnerable to attack, he is in a constant state of anxiety. Because he is in a constant state of anxiety, he may just be telling the truth about what happened that night. Pistorius responded to the noise in the bathroom as if it were a starting pistol: instantly and without thought. Because he could not take flight, he had no alternative but to stay and fight.

There is a superficial plausibility to this. Notice its similarity to the testimony of Merryl Vorster who diagnosed Pistorius with Generalized Anxiety Disorder. Who wouldn’t feel vulnerable and anxious in some situations if their lower legs, along with their feet, had been amputated. And yet, as Prosecutor Nel pointed out to Dr. Versveld, Pistorius moved around on his stumps, in the dark, and managed to fire four shots without falling over once. How so? Dr. Verseld had no answer. But here’s one: People with similar disabilities, in similar circumstances, can act in markedly different ways. Some capitulate and fold. Others fight back and overcome. We cannot ‘read off’ the response from the disability. Indeed, Pistorius himself is the living example of this. He rose above his disability to become a world class athlete. It’s not inconceivable that he could rise above any feeling of vulnerability. There are certainly many precedents.

Two blocks from where I write is the Sir Douglas Bader Towers in Edmonton, Alberta. It is home to several dozen paraplegics. They are often seen in their wheelchairs moving about the community. Their high-rise home is named after Douglas Bader who lost both legs in a flying accident in 1931. Against all odds, he returned as an Royal Air Force pilot with the outbreak of the Second World War in 1939, and fought with considerable success in the Battle of France and the Battle of Britain with crude artificial legs. No anxiety about how he would survive being shot down with no legs; or if there was he didn’t heed it.

In 1941 he was shot down over German-occupied France and was captured. Despite having no legs, Bader attempted to escape several times, for which he was sent to Colditz POW camp, where he remained until April 1945. When the war ended he campaigned for the disabled. ‘A disabled person who fights back is not disabled …. but inspired’.

In all walks of life, people endure extraordinary hardships; some overcome their circumstances; others submit to them. Being placed in one diagnostic category or another is no guide to how that person is going to act. As Bader put it:

The difficulty of discussing a personal disability such as the loss of an arm or a leg or eyes is that it affects different people differently. Someone else writing about an identical disability would almost certainly react in a totally different way.’

Throughout his athletic career, Pistorius has sought to downplay the impact of his disability. “I’m not disabled,” Oscar Pistorius told a British journalist in 2005. “I just don’t have any legs.” Just so.

The Pistorius Disorder

None of the proffered taxonomic categories help us in trying to understand what happened between Pistorius and Steenkamp that night. But we can imagine one that does. Regardless of his guilt or innocence, the circumstances of that deadly evening have all the ingredients of domestic violence. Paraphrasing Nietzsche, and in the style of the Diagnostic and Statistical Manual, here are the diagnostic criteria of the Pistorius Disorder:

  1. The person desires unconditional and sole possession of the person for whom he longs.
  2. The person wants to be loved and desires to live and rule in the other’s soul as supreme and supremely desirable.
  3. The person aims at the impoverishment and deprivation of all competitors for the affections of the person for whom he longs.
  4. This lust for possession is rooted in the emotions of romantic love and sexual desire.
  5. The person is prepared to go to any lengths, make any sacrifice, to disturb any order, to subordinate all other interests to retain the affections of the person for whom he or she longs. To this end:
    • The person engages in words and actions which attempt to monitor and control the beloved.
    • The person is susceptible to violent rages when these attempts fail.
    • The person immediately and quite genuinely regrets their violent behaviour. Or:
    • The person attempts to rationalize this controlling and violent behaviour.
  6. These possessive behaviours are rooted in jealousy, a volatile cocktail of fear (of losing her/his to another) and anger (at her/his treachery).
  7. Women are susceptible to this disorder too. The gender of the sufferer is less important than the nature of the emotional connection between the two people. Both suffer, albeit in very different ways.

This is no arbitrary cluster of behaviours with no cause. Nor is it a problem confined to individual persons, for the body is not self-contained. Social relations do not stop at the skin, they permeate the body in the form of social emotions. The Pistorius Disorder is a problem of diseased social emotions, manifest in people.